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  • The answer is you can increase your cancer risk if you overuse your barbecue. Research shows grilling and broiling meat creates cancer-causing substances—especially if they're well done or burnt. However, this idea is still a theory. It makes sense to limit your exposure to those chemicals, but the best nutrition advice for preventing cancer is to choose a diet consisting mostly of vegetables, fruits, and whole grain products.
  • The answer is you can increase your cancer risk if you overuse your barbecue. Research shows grilling and broiling meat creates cancer-causing substances—especially if they're well done or burnt. However, this idea is still a theory. It makes sense to limit your exposure to those chemicals, but the best nutrition advice for preventing cancer is to choose a diet consisting mostly of vegetables, fruits, and whole grain products.
  • Available evidence does NOT suggest a link between household use of pesticides and cancer. On the other hand, these products can be dangerous if precautions regarding breathing and direct contact are not followed. Precautions for pesticide use are especially important for agricultural workers who may be exposed at higher levels than people who occasionally spray a bug in their home or garden.
  • Air pollution does contribute to lung cancer risk, but has a greater impact on heart disease, asthma, and chronic bronchitis. Being a smoker, or even being frequently exposed to second hand smoke is more dangerous than the level of air pollution encountered in US cities.
  • It’s common for people to pay more attention to an injured part of their body, and some people discover tumors while rubbing a painful area. This doesn’t mean that the injury caused the cancer. In rare cases, longstanding injuries that don’t heal can increase cancer risk, but these account for a small fraction of cancer cases. Longstanding infections, such as certain forms of hepatitis or the bacteria that contribute to stomach ulcers, lead to more cancers than injuries do.
  • The kind of radiation emitted by cell phones, microwave ovens, and related appliances does not cause the kinds of DNA changes that are caused by ionizing radiation such as gamma rays and x-rays. The available evidence does not implicate cell phones as a cause of cancer. Keeping your hands free and your eyes on the road while driving is a more significant issue.
  • Most cases of cancer are the consequence of many years of exposure to several risk factors. What you eat, whether you are physically active, whether you are sunburned, and especially, whether you smoke as a young person have a substantial influence on whether you develop cancer later in life.
  • Specialists in cancer surgery know how to safely take biopsy samples and to remove tumors without causing spread of the cancer. In many cases, surgery is an essential part of the cancer treatment plan.
  • Charts on p 420
  • Recognize symptomsIdentify and manage underlying causeIron supplements may be neededConsider transfusionsConsider recombinant erythropoietinSymptom managementMonitor labs
  • Maintain bleeding precautionsPrevent injury & provide safe environmentMaintain integrity of skin, GI, GU systemsAdminister platelet transfusionsInstruct patient on safety measures (i.e. preventing injury, medications to avoid, symptoms to report)
  • Treat prophylacticallySelect appropriate antiemetic based on treatment regimenConsider cumulative effectsAdminister through entire anticipated period of nausea and vomiting
  • See page 423, chart 24-8
  • Mouth care q 2Avoid commercial mouthwashes that contain alcoholSoft toothbrush, unless plt<40K then no toothbrush, toothettes or gauze only.MILD stomatitis: generalized erythema, limited ulcerations, small white patches 1. NS rinses q 2 while awake, q 6 @ noc 2. Remove dentures except for meals 3. Avoid spicy foodsSEVERE stomatitis: confluent ulcerations, with white patches covering > 25% of mucosa 1. Obtain tissue c/s as ordered 2. Cleanse as prescribed – toothettes or gauze 3. Pain control with systemic analgesic I.e. MS gtt.Lip lubricant for both
  • Appearance of the face, neck, upper arms, and chest in a patient with superior vena cava syndrome.
  • I&O: Because the patient was admitted with dehydration, it is very important to monitor I&O.Using port for blood draws/IV fluids: When the patient has nausea and vomiting, you often see a decrease in electrolytes from the excessive fluid volume loss.Call for vomiting or >100° F temp: Any temperature elevation may be a sign of infection and should be reported immediately.D5½NS: This is to replace fluids.Ondansetron: This medication is to prevent nausea and vomiting caused by cancer chemotherapy.Clear liquid diet: This is to replace fluids and to provide some nutrition with decreased risk of nausea and vomiting.CBC, Ca, BMP: When the patient has nausea and vomiting, you often see a decrease in electrolytes from the excessive fluid volume loss.Bed rest, bathroom privileges: Because the patient is weak and dehydrated, these restrictions are for safety. Having bathroom privileges is often less stressful than using a bedpan.Knee-high stockings: There is a concern for DVT with prolonged bedrest, so support hose is ordered for the patient to increase venous return and prevent pooling of the blood.
  • ANS: ABased on the patient’s diagnosis, IV fluids should be started first. The patient is admitted with dehydration, so the Groshong port should be accessed and IV fluids initiated immediately. The provider has ordered clear liquids, but because the patient has been experiencing nausea and vomiting, she may not be able to ingest enough fluids to correct the dehydration. The laboratory values are ordered for the morning, so they should not be obtained until then. The support stockings can be obtained by the UAP while IV fluids are started.
  • The patient is most likely experiencing mucositis (sores in mucous membranes). With chemotherapy mucous membrane cells are killed more rapidly than they are replaced, resulting in the formation of mouth sores. Mouth sores are painful and interfere with eating.Examine the mouth and between the teeth every 4 hr for fissures, blisters, lesions, or drainage. Document the findings. Provide frequent good mouth care. Encourage the patient to avoid mouthwashes that contain alcohol. For mouth care, use a soft-bristled toothbrush or disposable mouth sponges. Do not use dental floss or pressure gum cleaners. Rinse the mouth with ½ peroxide and ½ normal saline every 8 hr. Normally the patient should drink at least 2 L of fluids, but due to the patient’s nausea and vomiting, this isn’t possible. Continue to monitor IV fluid replacement.(See Chart 24-9, in textbook, p. 424.)
  • ANS:A (Anemia) = 3 (Administer epoetin alfa subcutaneously once a week.)B (Neutropenia) = 1 (Inspect IV sites every 4 hours for signs of infection.)C (Thrombocytopenia) = 2 (Avoid IM injections and venipunctures.)

Transcript

  • 1. Presented by: Marsha Woodall MBA, MSN, RN Revised 2012 For NIP 210
  • 2. Objectives:  Relate the incidence of cancer and determine the role of nurses in the prevention and early detection of cancer.  Differentiate between benign and malignant neoplasms.  Identify factors which may contribute to the development of cancer.  Explain local and systemic effects of cancer.
  • 3. Objectives cont. Review the latest American Cancer Society statistics. Identify some specific chemotherapeutic agents. Summarize the socio-cultural considerations of caring for clients with cancer.
  • 4. Epidemiology Affects every age group  Leading causes of cancer Most occur in people in men: lung, prostate, over age 65 colorectal More than 1.2 million  Leading causes of cancer Americans are diagnosed in women: lung, breast, each year colorectal More than 560,000 deaths/yr in USA
  • 5. True or FalseThe risk of dying from cancer in the US is increasing.
  • 6. Pathophysiology of theMalignant Process CANCER is a disease process that begins when an abnormal cell is transformed by the gentic mutation of the cellular DNA. This begins to proliferate abnormally invading tissues,lymph & blood vessels which carry the cells to other areas of the body. This is called METASTASIS.
  • 7. Characteristics of Benign and Malignant Neoplasms(Refer to Table 23-1 on page 402)  Benign  Malignant Cell Characteristics Mode of Growth Rate of Growth Metastasis General Effects
  • 8. Cancer Development (MalignantTransformation) Initiation Promotion Progression Metastasis Extension into surrounding tissues Penetration into blood vessels Release of tumor cells Invasion of tissue
  • 9. Metastatic Mechanisms Local Seeding Bloodborne Metastasis Lymphatic Spread
  • 10. Etiology Chemical Agents Physical Agents Viruses Dietary Factors Immune function Genetic and Familial Factors Age Genetic Risk
  • 11. True or FalseRegularly eating meat cooked on a charcoal grill won’t increase you risk for cancer
  • 12. True or FalseYou can prevent skin cancer by putting on one application of sunscreen at the start of each day.
  • 13. True or FalseHousehold bug spray can cause cancer
  • 14. True or FalseLiving in a polluted city is a greater risk for lung cancer than smoking a pack of cigarettes a day
  • 15. True or FalseSome injuries can cause cancer later in life.
  • 16. True or FalseElectronic devices, like cell phones, can cause cancer in the people who use them.
  • 17. True or FalseWhat someone does as a young adult has little impact on his or her chances of getting cancer later in life.
  • 18. Cancer Assessment Considerations See chart 23-9 p. 405 C hange in bowel or bladder habits A sore that does not heal U nusual bleeding or discharge T hickening or lump in breast or other part of body I ndigestion or difficulty in swallowing O bvious change in wart or mole N agging cough or hoarseness
  • 19. Detection and Prevention ofCancer Primary Prevention: Nurses play a key role in cancer prevention  Avoidance of Known carcinogens  Modification of associated factors  Removal of “at risk” tissues  Chemoprevention
  • 20. Detection and Prevention ofCancer Secondary Prevention:  Promotion of cancer screenings  Gene therapy for cancer prevention
  • 21. Stages of Cancer Cell Invasion  In situ – noninvasive neoplasm  Localized – invasive neoplasm confined to the organ of origin  Regional – invasive neoplasm that extends into surrounding tissue  Distant – a neoplasm that spreads to distant parts of the body
  • 22. STAGING: Determines the size of the tumorand the existence of metastasis. TNM system; T = extent of primary tumor N = lymph node involvement M = extent of metastasisGRADING: Classification of tumor cellsobtained through cytology (biopsy). I to IV: I = Closely resemble tissue of origin IV = Poorly differentiated (more aggressive and less responsive to treatment)
  • 23. Question 1What are the odds of a man dying fromcancer in the U.S.?A. 1 in 2B. 1 in 4C. 1 in 25D. 1 in 50
  • 24. Question 2What race has the highest incidence ofcancer?A. African AmericanB. Hispanic/LatinoC. AsianD. Caucasian
  • 25. Question 3An example of a primary preventionstrategy for reducing cancer risk would be:A. Yearly mammography for women older than 40 yearsB. Regular physical exerciseC. Colonoscopy at age 50 years and then every 10 yearsD. Avoiding red meat in the diet
  • 26. Cancer Therapy Goals andResponsePrevention NeoadjuvantCure Chemo-Control preventionPalliation MyeloablationAdjuvant Immuno- suppression p. 17
  • 27. Management of Cancer Surgery  Diagnostic  Primary Treatment  Prophylactic  Palliative  Second-look  Reconstructive or rehabilitation
  • 28. True or FalseTreating cancer with surgery causes it to spread throughout the body.
  • 29. Treatment Strategies Combination versus single-agent therapy Dose or dose intensity of chemotherapy p. 18 Hormone receptor status
  • 30. Measuring Response Complete response (CR) Partial response (PR) Stable disease (SD) Progressive disease (PD) Relapse p. 19-20
  • 31.  Radiation Therapy (See charts on p. 420)  Ionizing  Control malignant disease  Palliative  External (teletherapy)  Internal (brachytherapy)  Dosage  Toxicity  Skin  Mucous membranes  Bone marrow
  • 32. Best Practice for Patient Safety& quality Care andpatient/family education See page 417
  • 33. Chemotherapy  Antineoplastic agents used to kill tumor cells by interfering with cellular functions and reproduction  Used primarily to treat systemic disease  Goals:  Cure  Control  Palliation
  • 34. Cell Cycle G1 phase - RNA and G2 protein synthesis S phase - DNA synthesis G2 phase - M S premitotic; DNA synthesis complete Mitosis - cell division occurs Go phase - Rest G1 Go
  • 35. Classification of Chemo agents Cell cycle - specific drugs Cell cycle - nonspecific drugs Alkylating agents Nitrosureas Antimetabolites Antitumor antibiotics Plant alkaloids Hormonal agents Miscellaneous agents
  • 36. Alkylating Agents Breaks DNA helix strand, thereby interfering with DNA replication Agents given via different routes depending on the medication
  • 37. Alkylating Agents Examples:  Carboplatin (Paraplatin)  Cis-Platinum, Platinol  Cyclophosphamide (Cytoxan)  Dacarbazin (DTIC)  Thiotepa (Thioplex)
  • 38. Antimetabolites  Incorporate into the normal cell constituents making them nonfunctional  Inhibit the normal function of a key enzyme  Acts in S phase; inhibits production for DNA synthesis. Leading to strand breaks of premature chain termination
  • 39. Chemotherapy Agents Antimetabolites capecitabine (Xeloda) cytarabine (Cytosar-U) floxuridine (FUDR) fludarabine (Fludara) fluorouracil (Efudex)
  • 40. Antitumor Antibiotics Inhibit DNA-dependent RNA synthesis or delay or inhibit mitosis bleomycin (Blenoxane) dactinomycin (Cosmegen) daunorubicin (Cerubidine) doxorubicin (Adriamycin PFS) epirubicin (Ellence)
  • 41. Nitrogen Mustards Disrupts normal nucleic acid function in DNA and RNA to inhibit reproduction chlorambucil (Leukeran) estramustine (Emcyt) mechlorethamine (Mustargen) melphalan (Alkeran) thiotepa
  • 42. Plant AlkaloidsInhibit formation of spindle fibers, arresting themetaphase stage of cell division docetaxel (Taxotere) etoposide (VePesid) irinotecan (Camptosar) paclitaxel (Taxol) vinblastine (Velban) vincristine (Oncovin, Vincasar PFS)
  • 43. Cytoprotective (Rescue) Agents Administered to reduce side effects and toxicity of chemotherapeutic agents Chemotherapy agent must be active long enough to kill malignant cells Then the rescue agent is given to prevent destruction of healthy cells  amifostine (Ethyol)  dexrazoxane (Zinecard)  leucovorin
  • 44. Routes of Administration  Oral  Subcutaneous or intramuscular  Itra-arterial  Intrathecally  Intraperitoneal  Intrapleural  Intravesicular  Intravenous p. 95
  • 45. Intrathecal route
  • 46. Mediport orPortacath
  • 47. Vesicants  Agents that cause extravasation if deposited into subq tissue  Vesicants are:  Dactinomycin  Daunorubicin  Adriamycin  Nitrogen mustard  Mitomycin  Vinblastine  Vincristine  Vindesine
  • 48. Indications of Extravasation  Absence of blood return from the IV  Flow is resistant  Swelling, pain, or redness at site Venous access device • Referred to as VAD • Inserted to promote safety while administering vesicants • Complications: infection, thrombosis
  • 49. S/S associated with vesicant extravasation,irritation and flare reaction  Pain  Redness  Swelling  Blood return  Ulceration p. 107
  • 50. Toxicity with chemotherapy GI  Nausea/Vomiting  Stomatitis/Mucositis Myelosuppression  Leukopenia  Anemia  Thrombocytopenia  Neutropenia Renal  Cisplatin, MTX, Mitomycin = Kidney toxicity  hyperkalemia, hyperphosphatemia, hypocalcemia  Monitor BUN, serum creatinine, creat inine clearance,electrolytes
  • 51. • Cardiopulmonary – Daunorubicin, Doxorubicin may cause irreversible cardiac toxicities – Bleomycin, BCNU, Busulfan cause lung toxicities (pulmonary fibrosis)• Reproductive – possible sterility• Neurological – Vincristine can cause peripheral neuropathy, loss of deep tendon reflexes, paralytic ileus – Cisplatin can cause peripheral neuropathy and hearing loss • Fatigue
  • 52. GENERAL SIDE EFFECTS OF CHEMOTHERAPEUTIC DRUGSImmediate side effects: Nausea, vomiting, fever, allergy, hypotension, arrhythmia, thrombophlebitisReversible side effects: Bone marrow suppression (leucopenia, thrombopenia), inflamed mucosa, stomatitis, enteropathy, diarrhea, alopecia, changes in skin pigmentation, hyperkeratosis, hepatotoxicity, nephrotoxicity, amenorrhea, aspermogenesisIrreversible side effects: Cardiotoxicity, hepatotoxicity, nephrotoxicity, neurotoxicity, ototoxicity, mutagenesis/carcinogenesis-> malignancyIndirect effects: Immunosuppression, increased infection rate, increased blood urea (kidney failure)
  • 53. Systemic side Effects Chemotherapy causes side effects by exerting its greatest effect on rapidly generating cells Chemotherapy + radiation, biologic and/or hormonal therapy = increased toxic effects Physiological deficits and co-morbidities can enhance toxicities
  • 54. Myelosuppression Suppression of bone marrow activity Can result in a decrease in any combination of WBC, RBC or platelets Most common dose-limiting toxicity Potentially LETHAL
  • 55. Nadir Point at which the lowest blood-cell count is reached Usually 7-10 days after treatment Onset and duration depends on agent used WBC & platelets are usually 1st to drop Anemia is seen later
  • 56. Neutropenia  Bone marrow constantly produces neutrophils  Life span of neutrophil is 7-12 hours  Chemo agents suppress bone marrow and damage stem cells  Resulting in decreased neutrophil count as mature neutrophils die & aren’t replaced
  • 57. Anemia RBC production is result of erythropoiesis, which is regulated by erythropoietin (EPO) Normal erythrocyte life span = 120 days Delayed anemia effects due to limited bone marrow reserve and late effects of treatment Difficult to limit to single etiology
  • 58. Thrombocytopenia  Destruction or injury to stem cells leads to dysfunction and suppression of platelet production  Normal life span – 7-10 days  No bone marrow reserve of precursors  Some chemo agents have thrombocytopenia as their dose-limiting toxicity
  • 59. Thrombocytopenia assessment Petechiae/bruising  Headaches Overt bleeding  Hypotension Enlarged liver or  Tachycardia spleen  Prolonged Occult or overt menstruation blood in stool or urine
  • 60. Risk of Bleeding Platelet Count Risk level/intervention 100,000  Chemotherapy reduced or held 50,000  Increased risk of bleeding; initiate precautions (no injections, etc.)  Severe risk exists for <15,000 spontaneous hemorrhage; frequent check of platelet counts/transfusions
  • 61. Nausea and Vomiting Anticipatory – occurs before or during treatment (25% incidence) Acute – occurs within 24 hours Delayed – occurs at least 24 hours after therapy and may persist up to 6 days (Cisplatin associated with highest incidence)
  • 62. Antiemetic Therapy for CINV Ondansetron (Zofran) Granisetron (Kytril) Granisetron transdermal (Sancuso) Dolasetron (Anzemet) Palonosetron (Aloxi)Drug combinations are individualized for best effect
  • 63. MucositisClinical Manifestations Taste changes  Changes in color of Swallowing oral mucosa difficulty  Oral moisture Hoarseness changes Pain with  Edema swallowing or  Ulcerations talking
  • 64. Mucositis Assessment Perform thorough oral assessment:  Standard instrument  Penlight  Gloved finger  Inspect under tongue and along inner cheeks, gums, inspect hard & soft palate
  • 65. Mucositis Management Prevention Treatment Oral care protocols  No evidence-based Patient education recommendations Treat dental problems  Goal is symptom relief, before cytotoxic therapy prevention of further High protein diet damage  Oral agents & hygiene Fluid intake > 1500 ml/d  Systemic pain Cryotherapy ofr bolus 5- FU medications  Culture lesions
  • 66. Hormonal Manipulation Some hormones make hormone-sensitive tumors grow more rapidly. Some tumors require specific hormones to divide; decreasing the hormone amounts to hormone- sensitive tumors can slow cancer growth rate
  • 67. Side Effects ofHormone Therapy Masculinizing effects in women Feminizing effects in men (gynecomastia) Risk for venous thromboembolism Acne Hypercalcemia Liver dysfunction Bone loss
  • 68. Photodynamic Therapy Selective destruction of cancer cells via chemical reaction triggered by different types of laser light Patient teaching General sensitivity to light for up to 12 weeks after injection of photosensitizing drug
  • 69. Fatigue (#1 complaint) Definition: Persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning
  • 70. Fatigue Risk Factors Malnutrition  Comorbidities Immobility  Hypoxia Insomnia  Infection/fever Stress  Pain Depression/anxiety  Cancer therapy Anemia
  • 71. Immunotherapy: BiologicalResponse Modifiers (BRMs) Modify patient’s biological responses to tumor cells Cytokines—enhance immune system Interleukins, interferons Side effects—generalized, sometimes severe inflammatory reactions, peripheral neuropathy, skin rashes
  • 72. Colony-stimulating factors Aranesp and Procrit  Stimulates erythropoiesis  Administered SC Neupogen  Regulates the production of neutrophils within the bone marrow  Administered SC, IV
  • 73. Colony-stimulating factors  Neulasta  Regulates the production of neutrophils within the bone marrow  Administered SC  GM-CSF  Induces committed progenitor cells to divide and differentiate in the GM pathways  Administered SC, IV
  • 74. Oncologic Emergencies Sepsis and disseminated intravascular coagulation Collaborative management includes:  Prevention (the best measure)  Intravenous antibiotic therapy  Anticoagulants, cryoprecipitated clotting factors
  • 75. Syndrome of Inappropriate AntidiureticHormone (SIADH) Water is reabsorbed to excess by the kidney and put into system circulation. SIADH is most commonly found in carcinoma of the lung Collaborative management includes:  Fluid restriction  Increased sodium intake  Drug therapy with demeclocycline that works in opposition to antidiuretic hormone
  • 76. Spinal Cord Compression Tumor directly enters the spinal cord or the vertebrae collapse from tumor degradation of the bone. (Continued)
  • 77. Spinal Cord Compression (Continued) Collaborative management includes:  Early recognition and treatment  Palliative  High-dose corticosteroids  High-dose radiation  Surgery  External back or neck braces to reduce pressure in the spinal cord
  • 78. Hypercalcemia Occurs most often in clients with bone metastasis Fatigue, loss of appetite, nausea and vomiting, constipation, polyuria, severe muscle weakness, loss of deep tendon reflexes, paralytic ileus, dehydration, electrocardiographic changes (Continued)
  • 79. Hypercalcemia (Continued) Collaborative management includes:  Oral hydration  Drug therapy  Dialysis
  • 80. Superior Vena Cava Syndrome Superior vena cava is compressed or obstructed by tumor growth. Condition can lead to a painful, life- threatening emergency. Signs include edema of face, Stokes’ sign, edema of arms and hands, dyspnea, erythema, and epistaxis. (Continued)
  • 81. Appearance of SVC Syndrome
  • 82. Superior Vena Cava Syndrome (Continued) Late-stage signs include hemorrhage, cyanosis, change in mental status, decreased cardiac output, and hypotension. Collaborative management includes high- dose radiation therapy, but surgery only rarely.
  • 83. Tumor Lysis Syndrome Large numbers of tumor cells are destroyed rapidly, resulting in intracellular contents being released into the bloodstream faster than the body can eliminate them. Collaborative management includes:  Prevention  Hydration  Drug therapy
  • 84. A 40-year-old woman was admitted to the oncologyunit for severe dehydration from nausea andvomiting associated with chemotherapy 10 days ago.She has had two adjuvant treatments for breastcancer with doxorubicin (Adriamycin) andcyclophosphamide (Cytoxan). She has a Groshongport that was inserted 2 months ago forchemotherapy administration.
  • 85. (cont’d)The health care provider’s orders are as follows: Strict I&O every 12 hours May use port for blood draws and IV fluids Call for vomiting or temp of 100° F or greater D5½NS at 125 mL/hr Ondansetron (Zofran) 8 mg IV every 8 hrs Clear liquid diet and progress as tolerated CBC, Ca level, and basic metabolic panel in AM Bed rest with bathroom privileges Knee-high support stockingsWhat is the rationale for each of the provider’s orders?
  • 86. (cont’d)Which of the provider’s orders should beimplemented immediately?A. Administer D5½NS at 125 mL/hrB. Administer clear liquid dietC. Apply support stockingsD. CBC, Ca level, and basic metabolic panel
  • 87. (cont’d )Two hours later, the patient reportsdifficulty swallowing because of sores inher mouth.1. What does the nurse suspect is the problem with the patient’s mouth?2. What nursing interventions should be implemented?
  • 88. (cont’d )Match each chemotherapy side effect below withthe correct intervention.A. AnemiaB. NeutropeniaC. Thrombocytopenia1. Inspect IV sites every 4 hours for signs of infection.2. Avoid IM injections and venipunctures.3. Administer epoetin alfa subcutaneously once a week.
  • 89. Audience Response System Questions 124
  • 90. Question 1What is the expected outcome related to hairloss for a patient who is undergoingchemotherapy?A.Hair loss may be permanent.B. Hair regrowth usually begins about 1 month after completion of chemotherapy.C.New hair growth will likely be identical to previous hair growth in color and texture.D.Viable treatments exist for the prevention of alopecia.
  • 91. Question 2A patient who is receiving radiationtherapy for breast cancer would experiencewhich side effect?A.FatigueB. MucositisC.Hair lossD.Nausea and vomiting
  • 92. Question 3When is the patient with acute leukemia atgreatest risk of developing tumor lysissyndrome?A.After the first cycle of chemotherapyB. After the second cycle of chemotherapyC.After the last cycle of chemotherapyD.Anytime during the patient’s treatment course