Review of Hematology, Oncology and

Cardiac Diseases for ACN FALL 2016

Jansi Rani Natarajan
 WHAT IS CANCER?

Cancer is a neoplastic disorder that occur in any organ of

the body. It is the abnormal or uncontrolled growth of
cells

Classification
1. Solid tumours - organs
2. Haematological cancers – blood cell forming tissues
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 Types of Cancer
– Classified according to the types of cells.
• Initially retain some of the original properties of the host cell.
• Carcinomas - most common - arises from the epithelial tissue
that cover body surfaces. Linings, tubes, cavities and secretion
glands.
• Sarcomas: arise in connective and fibrous tissues. Bone, muscle,
cartilage and membranes covering muscle or fat.
• Lymphomas: Cancers of the lymph nodes (neck, armpit, and
groin).
• Leukemia: cancer of the blood-forming cells in bone marrow.

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 Grading and Staging

Grading: Staging
• I – Mild dysplasia • 0 – Carcinoma in situ
• II – Moderate dysplasia • I – localized tumor
• III – Severe dysplasia growth
• IV – Anaplasia • II – Limited local spread
• III – Extensive local and
regional spread
• IV – Distant metastasis

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 Factors that influence cancer development

Environmental
• Chemical
• Physical
• Viral
• Helicobacter pylori infection

Obesity and dietary factors

• Preservatives
• Contaminants
• Additives
• nitrates

Genetic predisposition
Age
Immune function

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 Tumor Development

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 HOW DOES CANCER DEVELOP?

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 Cancer’s Seven Warning Signals

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 Diagnostic Tests

• Biopsy • MRI
• Bone marrow • Evaluation of serum
examination tumor markers
• Chest radiograph • Proctoscopy
• CBC examination
• CT • Radiography(Mammogr
• Cytology (PAP) aphy)
• LFT • Radioisotope scanning

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 Chemotherapy
S: 6-8 hours

G1: 8 or
G2: 2-5hours
more hours

G0:
Indefinite Mitosis
time

Cell Cycle specific :

• Most active against cells in a specific Uses:
phase therefore need prolonged •NEOADJUVANT – Combined with
exposure or repeated doses. surgery and radiation
Cell Cycle Non-specific: •ADJUVANT – Post operatively to
• Most effective against actively dividing
cells but also effective in G0. destroy remaining tumour cells
•PRIMARY – treat some forms of
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 CLASSIFICATION
Cell-cycle Nonspecific
Alkylating agents - Alters DNA structure
Busulfan, Cisplatin
Nitrosoureas - Alters DNA structure; crosses blood
Carmustine, Lomustine brain barrier

Antitumor antibiotics - Interferes with the RNA and DNA

Bleomycin, synthesis
Daunarubicin
Hormonal agents - Bind to hormone receptor sites that
Androgens, alter cellular growth
Antiandrogens,
Estrogens,
Antiestrogens, etc
Cell-cycle Specific
Topoisomerase I Prevents cell from dividing (S-
inhibitors - phase)
Irinotecan
Anitimetabolites - Interferes with the biosynthesis of
Azacytadine, metabolites or nucleic acids
Cytarabine, 5- necessary for RNA and DNA
fluorouracil, synthesis (S-phase)
Hydroxyurea,
Methotrexate
Mitotic spindle poisons Inhibit DNA and protein synthesis
(Plant alkaloids) (M-phase)
Etoposide, Vinblastine,
Vincristine

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 Renal System:
damage occurs due Cardiopulmonary Reproductive
to their direct System: System:
Hematopoietic effects during Anthracyclides can Sterility, early Neurologic
Gastrointestinal System: excretion and the cause irreversible menopause is System:
System: myelosuppression accumulation of cardiac toxicities. common among Metabolic Fatigue
Nausea and leading to increased end products after Pulmonary fibrosis women encephalopathy
vomiting risk of infection and cell lysis Capillary leak In men temporary Peripheral
bleeding Hemorrhagic syndrome leading or permanent neuropathies
cystitis can manifest to pulmonary azospermia may
from microscopic to edema develop
frank bleeding

Anticipate
febrile Monitoring
neutropenia 7 BUN,
to 14 days after creatinine and Cytoprotective
administration electrolytes is agents
Medications (Dexrazoxane)
like serotonin of essential
chemotherapy can prevent
blockers these toxicities
(ondansetron),
dopaminergic Adequate
blockers Colony hydration,
(metocloprami Stimulating diuresis and
de) Factors are alkanization of
administered urine can
to stimulate prevent
the bone formation of
marrow to uric acid These effects
produce WBCs crystals in Patients at risk Banking of are usually Can last for
urine are monitored sperms before reversible, but
months after
closely for treatment is may take few treatment
changes in PFT recommended months to be
restored
Erythropoietin Allopurinol
stimulate may be used to
production of prevent these
RBCs side effects
Non-
pharmacologic
al approaches:
small frequent
meals, bland Interleukin 11 Sudden onset
foods stimulated Mesna is a of respiratory
production of cytoprotective distress is be
platelets (can agent that reported
cause toxic binds with the
symptoms like toxic
fatigue, metabolites
edema, etc)
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 Radiation Therapy

• Radiation therapy works by damaging the DNA

within cancer cells and destroying their ability to
reproduce.

TELETHERAPY OR EXTERNAL BEAM

RADIOTHERAPY USES X-RAY BEAMS OF
VARIOUS ENERGIES

BRACHYTHERAPY USES SEALED

SOURCES OF RADIATION TO DELIVER A
HIGH DOSE TO A TUMOUR AND CAN
INVOLVE INTERSTITIAL THERAPY OR
IMPLANTS OR INTRACAVITY
TREATMENT

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 Types of Radiotherapy

TELETHERAPY OR EXTERNAL BEAM RADIOTHERAPY USES

X-RAY BEAMS OF VARIOUS ENERGIES

BRACHYTHERAPY USES SEALED SOURCES OF RADIATION

TO DELIVER A HIGH DOSE TO A TUMOUR AND CAN
INVOLVE INTERSTITIAL THERAPY OR IMPLANTS OR
INTRACAVITY TREATMENT

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 SIDE EFFECTS OF RADIOTHERAPY

Side effects: Client education

• Skin reaction • Wash the area gently with
• Hair loss warm water or mild soap
• Diarrhoea • Do not remove the
• Mucositis markings
• Sterility • Use no powders,
• Frequency of passing urine ointments, lotions or
• Fatigue creams at the radiation site
• Anorexia • Avoid exposure of the
• Psychological effects irradiated area to the heat
• Nausea and vomiting or sun

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 Bone marrow Transplantation or Peripheral
stem cell transplantation

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 Types of Donor stem cells

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03/31/2023 18
 Common cancers

• Skin cancer • Esophageal cancer

• Leukemia • Gastric cancer
• Lymphoma • Pancreatic cancer
• Multiple myeloma • Intestinal tumors
• Testicular cancer • Lung cancer
• Cervical cancer • Laryngeal cancer
• Ovarian cancer • Prostate cancer
• Endometrial cancer • Bladder cancer
• Breast cancer • Oncological emergencies

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 Prevention
• Lifestyle choices
– Avoid tobacco
– Controlling diet and weight
– Regular exercise
– Protecting skin from the sun
– Avoiding environmental and occupational carcinogens
Recommended screening tests
– Be aware of the early signs and symptoms

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 Review Questions
1. A female client with cancer is receiving chemotherapy and develops Neutropenia. The nurse identifies which intervention as the highest priority
in the nursing plan of care?
a) Monitoring temperature
b) Ambulation three times daily
c) Monitoring the platelet count
d) Monitoring for pathological fractures
2. A bone marrow Transplant where stem cells are taken either by bone marrow harvest or collected from peripheral blood stem cells from a
genetically matched donor is called
e) An antigenic BMT
f) An allogenic BMT
g) An autologous BMT
h) An umbilical cord transplant
3. A male client is receiving the cell cycle–nonspecific alkylating agent Cisplatin, as part of a chemotherapeutic regimen. How does cisplatin exert its
therapeutic effects?
i) It interferes with deoxyribonucleic acid (DNA) structure only.
j) It interferes with ribonucleic acid (RNA) transcription only.
k) It interferes with DNA replication and RNA transcription.
l) It destroys the cell membrane, causing lysis.
4. The nurse is caring for a female client experiencing neutropenia as a result of chemotherapy. The drug of choice for increasing the WBC count is:
m) Filgrastim
n) Epogen
o) Meropenam
p) Endoxan
5. For a female client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?
q) Administering aspirin if the temperature exceeds 102° F (38.8° C)
r) checking for gum bleeding once every shift
s) Providing for frequent rest periods
t) Placing the client in strict isolation

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 Sickle cell anemia

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 SCD
A serious condition in which red blood cells can become
sickle-shaped
Normal red blood cells are smooth and round. They move
easily through blood vessels to carry oxygen to all parts of
the body.
Sickle-shaped cells don’t move easily through blood. They’re
stiff and sticky and tend to form clumps and get stuck in
blood vessels.
The clumps of sickle cell block blood flow in the blood
vessels that lead to the limbs and organs. Blocked blood
vessel can cause pain, serious infection, and organ damage.

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 Normal and Sickled Red Blood Cells
in Blood Vessels
Figure B shows abnormal, sickled red blood cells clumping and
blocking the blood flow in a blood vessel. The inset image shows a
cross-section of a sickled red blood cell with abnormal strands of
hemoglobin.

Figure A shows normal red blood cells flowing freely in a

blood vessel. The inset image shows a cross-section of a
normal red blood cell with normal hemoglobin.

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Source from http://www.nhlbi.nih.gov/health/dci/Diseases/Sca/SCA_WhatIs.html 24
 Hereditary
Patterns
Genetics
 2 copies of the gene for
Hb (each parent)

 HbS – Recessive
 S=Sickle
 A=Normal

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 Sickle cell crisis

Anemia: Fatigue
(tiredness), pale skin and
nail beds, jaundice, and
shortness of breath
Pain (Sickle Cell Crisis):
Sudden episode of pain
throughout the body.
Common sites: bones, lungs,
abdomen, and joints. Lack
of blood flow can cause pain
and organ damage.

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 Major Clinical Manifestations

• Osteomyelitis
Acute painful episodes
• CVA
Multi-organ failure
• Bone
Psychosocial
complications
issues
• Infarct
Growthand& development
necrosis
• Marrow
Infectioninfarct
•-Bacteremia
Orbital compression
•-Meningitis
Arthritis
-Bacterial pneumonia
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 Treatments
• Effective treatments are available to help relieve the
symptoms and complications of sickle cell anemia, but
in most cases there’s no cure.
• The goal is to relieve the pain; prevent infections, eye
damage, strokes and control complications if they occur.
• Pain medicine: acetaminophen, non-steroidal anti-
inflammatory drugs (NSAIDs), and narcotics such as
meperidine, morphine, oxycodone, and etc.
• Hydroxyurea, Folic Acid
• Blood Transfusions (Exchange Transfusion)
• Bone marrow transplants
• Gene therapy
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 Prevention
Identify what can trigger the “Crisis” such as stress, avoid
extremes of heat and cold weather, don’t travel airplane
that is not cabin pressurized
Maintain healthy lifestyle habits
 Eating healthy
 Avoid dehydration
 Exercise regularly
 Get enough sleep and rest
 Avoid alcohol and don’t smoke
Regular medical checkups and treatment are important

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 Anemia
 Deficiency in the oxygen-
carrying capacity of the blood
due to a diminished
erythrocyte mass.
 May be due to:
 Erythrocyte loss (bleeding)
 Decreased Erythrocyte
production
low erythropoietin
Decreased marrow response
to erythropoietin
 Increased Erythrocyte
destruction (hemolysis)
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Clinical Manifestations:
• Decreased oxygenation
– Exertional dyspnea
– Dyspnea at rest
– Fatigue
– Bounding pulses
– Lethargy, confusion
• Decreased volume
– Fatigue
– Muscle cramps
– Postural dizziness
– syncope
30
 Anemia due to Decreased Response to
Erythropoietin
• Iron Deficiency
– Can result from:
– Pregnancy/lactation
– Normal growth
– Blood loss
– Intravascular hemolysis
– Gastric bypass
– Malabsorption
» Iron is absorbed in proximal
small bowel; decreased
abosrption in celiac disease,
inflammatory bowel disease
– May manifest as PICA
• Tendency to eat ice, clay, starch,
crunchy materials
– May have pallor, koilonychia of the
nails, beeturia
– Peripheral smear shows microcytic,
hypochromic red cells with
marked anisopoikilocytosis.

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 Iron Deficiency Anemia

• Lab findings:
Serum Iron
LOW (< 60 micrograms/dL)
Total Iron Binding Capacity (TIBC)
HIGH ( > 360 micrograms/dL)
Serum Ferritin
LOW (< 20 nanograms/mL)
Can be “falsely”normal in inflammatory
states
• Treatment:
Oral iron salts
– Ferrous sulfate – 325 mg po Q Day
• Side effects: constipation, black
stools, positive hemmoccult test
– Vitamin C can facilitate iron
absorption.
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 Anemia due to Decreased Response to
Erythropoietin
• Cobalamin (Vitamin B12) Deficiency
• Macrocytic anemia
• Vitamin. B12 is needed for DNA synthesis
• Binds to intrinsic factor in the small bowel in order to be absorbed
» Pernicious anemia: antibodies to intrinsic factor
» Diagnosed by checking antibody levels (rather than Schilling test)
• Deficiency can result in neuropsychiatric symptoms
» Spastic ataxia, psychosis, loss of vibratory sense, dementia
» Frequently not reversible with cobalamin replacement
Treatment:
• Vitamin B12 – 1000 micrograms intramuscularly monthly
-OR-
• Vitamin B12 – 1000-2000 micrograms Oral Daily

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 Anemia due to Decreased marrow response

• Thalassemia
• Microcytic anemia
• Defects in either the alpha or beta chains of
hemoglobin, leading to ineffective erythropoiesis and
hemolysis
– -thalassemia:
» Prevalent in Africa, Mediterranean, Middle East, Asia
– -thalassemia:
» Prevalent in Mediterranean, South East Asia, India,
Pakistan
• Smear shows microcytosis with target cells

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 Thalassemia

Definition: Thalassemia is inherited disorders characterized reduced or absent

amounts of hemoglobin, the oxygen-carrying protein inside the red blood cells. Genetic
blood disorder resulting in a mutation or deletion of the genes that control globin
production.
Normal hemoglobin is composed of 2 alpha and 2 beta globin. Mutations in a given globin
gene can cause a decrease in production of that globin, resulting in deficiency:
aggregates become oxidized, damage the cell membrane, leading either to hemolysis,
ineffective erythropoiesis, or both.
Types:
• Alpha(Results in excess of beta chains) and beta (Results in excess of alpha chains).

• Thalassemia Minor, Trait, Intermedia, Major (Cooley’s anemia)

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 Symptoms
Management
• Life-threatening
• Blood transfusions
Anemia
• Jaundice • Iron chelation therapy
-Removing Excess Iron
• Enlarged organs
present in transfused blood
• Misshapen bones
– Marrow “cracks” • Bone Marrow transplant

• Generally Smaller - A counter-measure in order

to decrease the hyperactivity

of the Bone Marrow

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 Hemophilia
• Hemophilia is an inherited
bleeding disorder in which
there is a deficiency or lack
of factor VIII (hemophilia A)
or factor IX (hemophilia B)
• Hemophilia A and B are X-
linked recessive disorders
• Hemophilia is typically
expressed in males and
carried by females
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Clinical manifestations:
• Nose bleeds
• Bruising
• Spontaneous bleeding
• Bleeding in joints
• Blood in urine or stool
• Prolonged bleeding from
cuts, tooth extraction, and
surgery
• Excessive bleeding following
circumcision
37
 Management
• Replacement of missing
clotting protein Complications:
– Factor VIII &IX Concentrates • Flexion contractures
• DDAVP (Vasopressin) • Joint arthritis / arthropathy
• Bleeding precautions • Chronic pain
• Anti-fibrinolytic Agents • Muscle atrophy
• Exercise so the muscle can
strengthen and protect joints. • Compartment syndrome
• Supportive measures • Neurologic impairment
– Rest
– Ice application
– Compression
– Elevation

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 Review questions
6. According to the WHO ladder for pain management, mild pain is managed by
a) Non opioid +/- Adjuvant
b) Weak opioid +/- non opioid
c) Strong opioid
d) Strong opioid +/- non opioid
7. Ms. Mariam is admitted to the hospital in a state of sickle cell crisis. Which of the following will be the most
helpful in reversing this episode and preventing a future crisis?
e) Prevention of dehydration
f) Institution of pain relief measures
g) Administration of anticoagulants prophylactically
h) Administration of diuretics to relieve edema
8. When treating Ms. Kadhija with sickle cell disease, for pain, it is important to explain to her and her family that:
i) Narcotics are used only when absolutely necessary
j) Aspirin, as an analgesic, is contraindicated
k) Morphine sulfate is the gold standard drug for pain relief
l) Acute painful episodes are not common
9. The nurse expects increase in the PT, APTT and bleeding time results of her patient if he is taking one of the
following drugs :
m) Enoxaparin
n) Lisinopril
o) Amlodipine
p) Digoxin

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 Anatomy of the Heart

03/31/2023 4015.4
Figure
 Types Of Cardiovascular Disease

• Atherosclerosis
• Coronary heart disease (CHD)
• Chest pain (angina pectoris)
• Irregular heartbeat (arrhythmia)
• Congestive heart failure (CHF)
• Congenital and rheumatic heart disease

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 New Weapons Against Heart Disease

• Techniques for diagnosing heart disease

– Cardiac markers- CK-MB, Troponin C,I,T, &Myoglobin
– CBC, Coagulation factors, lipids, Electrolytes, BUN, BNP,
– Electrocardiogram (ECG), Echocardiography,
– Digital subtraction Angiography
– Positron emission tomography (PET)
– Single positron emission color tomography (SPECT)
– Radionuclide imaging(MNPI)
– Magnetic resonance imaging (MRI)
– Ultrafast CT
– Cardiac Catheterization

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 Artherosclerosis
• Characterized by deposits of
fatty substances, cholesterol,
cellular waste products,
calcium, and fibrin in the inner
lining of the artery
• Hyperlipidemia – abnormally
high blood lipid level
• Plaque – the buildup of
deposits in the arteries

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 Angina Pectoris

• Ischemia – reduction of the heart’s blood and

oxygen supply
• The more serious the oxygen deprivation the
more severe the pain
• Nitroglycerin – drug used to relax (dilate) the
veins
• Beta blockers control potential over activity of
the heart muscle
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 Coronary Heart Disease

• Myocardial infarction (MI) or heart

attack – blood supplying the heart is Routine medical interventions:
disrupted – Supplemental oxygen
– Nitroglycerin
• Coronary thrombosis – blood clot in
– Morphine
the artery
– Aspirin 162 to 325 mg
• Embolus – when the blood clot is – Beta-blocker
dislodged and moves through the – Angiotensin-converting enzyme inhibitor
circulatory system within 24 hours
• Collateral circulation - if blockage to – Anticoagulation with heparin and platelet
inhibitors
the heart is minor, an alternative blood • Reperfusion therapy:
flow is selected – Percutaneous coronary intervention
ECG changes in MI – Thrombolytic therapy
• T-wave inversion • Other therapy:
– Intravenous heparin or low-molecular-weight
• ST-segment elevation heparin
• Development of an abnormal Q wave – Clopidogrel (Plavix)
– Bed rest for a minimum of 12 to 24 hours
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 Angioplasty and Bypass Surgery

• Percutaneous Transluminal
coronary Angioplasty – a thin
catheter is threaded through
the blocked arteries. The
catheter has a balloon on the
tip which is inflated to flatten
the fatty deposits against the
wall of the artery
• Coronary bypass surgery – a
blood vessel is taken from
another site and implanted to
bypass blocked arteries and
transport blood

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 Arrythmias
• An irregularity in heart rhythm • Cardioversion
• Tachycardia – racing heart in
the absence of exercise or
• Defibrillation
anxiety • Implantable
• Bradycardia – abnormally slow cardioverter
heartbeat defibrillator
• Fibrillation – heart beat is
sporadic, quivering pattern • Pace makers

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 Congestive Heart Failure (CHF)
• HF is the inability of the
heart to pump a sufficient
amount of blood to meet
the metabolical and
oxygen needs of the body
• Types: Acute and Chronic
• Right / left sided
• Forward / backward
• Low output / high output
• Systolic/Diastolic

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 Symptoms

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 Heart Failure-
(progression)

Mild
Mild CDHF(Pulmonary Edema) Irreversible – end stage

Control With
Needs a new ventricle
Emergency-
Drugs Upright position,
O2, morphine
Diet
VAD
Fluid IABP
Restriction Heart Transplant
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 Management of Heart Failure

• Correction of systemic factors

– Thyroid dysfunction
– Infections
– Uncontrolled diabetes
– Hypertension
• Lifestyle modification
– Lower salt intake
– Alcohol cessation
– Limit fluid intake
• Maximize medications
– Loop diuretics- Furosemide
– ACE inhibitor (or ARB if not tolerated) - Enalapril
– Beta blockers - Carvedilol
– Digoxin
– Hydralazine, Nitrate
– Potassium sparing diuretics - Spironolactone

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 Congenital And Rheumatic Heart Disease

• Common Congenital heart diseases are ASD,

VSD, PDA and TOF
• May be due to hereditary factors, maternal
diseases, or chemical intake (alcohol) during
fetal development
• Rheumatic heart disease results from
rheumatic fever which affects connective
tissues of the heart(Valves).

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 Reducing Your Risk For Cardiovascular
Diseases
• Risks you can control
– Avoid tobacco
– Cut back on saturated fat and cholesterol
– Maintain a healthy weight
– Modify dietary habits
– Exercise regularly
– Control diabetes
– Control blood pressure
• Systolic – upper number
• Diastolic – lower number
– Manage stress

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 Review Questions
10. Mr. Yousuf is 70 years old hypertensive patient. He is on Lisinopril 10mg tablet once daily at 8 am. After administering
this medication, you should instruct your patient to :
a) Maintain the same position (supine position) for minimum of 30 minutes.
b) Stop taking this medication if he feel that his condition improved
c) Not to change his position very fast.
d) If his blood pressure is around 120/80 , he should not take this medication.
11. Nurse Oliver checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains
a residual amount of 150 mL. What is appropriate action for the nurse to take?
e) A. Hold the feeding
f) B. Re instill the amount and continue with administering the feeding
g) C. Elevate the client’s head at least 45 degrees and administer the feeding
h) D. Discard the residual amount and proceed with administering the feeding
12. The patient has had biomarkers drawn after complaining of chest pain. Which diagnostic of myocardial infarction
remains elevated for as long as 2 weeks?
i) Myoglobin.
j) Troponin.
k) Total CK.
l) CK-MB.
13. A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial
ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see?
m) Prolonged PR interval.
n) Absent Q wave.
o) Elevated ST segment.
p) Widened QRS complex.
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