ORTHOPEDIC NURSING

ARTHRITIS
Arthritis: A Comparative Study:

Rheumatoid arthritis Osteo-arthritis Gouty arthritis

Cause: Autoimmune disease; Wear and tear/degenerative; Altered purine metabolism;
Age: Young (20-40 years old) 40s 30s
Weight: Tends to be underweight; Tends to be obese; ----
ESR: Always elevated; Normal; Elevated during attacks;
Labs Rheumatoid factor; None Increased uric acid levels;
Symmetric Symmetric; Depends on joint stress; Asymmetric;
Distribution:
Systemic Weakness, splenomegaly, None; Possible renal damage/stones;
symptoms: lymphadenopathy;
Joints Smaller joints of hands and Weight-bearing joints; Big toe, foot, and knee;
affected: feet;
Joint Pannus formation-bony Osteophyte formation; Tophi, outside red, dusky,
appearance: ankylosis; tender;
Joint pain Early morning, decreases with Pain after activity; During night time;
occurrence: activity;
Nodules: Subcutaneous nodules; Heberden’s / bouchard’s nodes; Tophi
Morning (+), more than 30 minutes; (-) or sometimes (+), (+) crepitus; (-)
stiffness:
Reversibility: (-) (-) (-)
Treatment: Corticosteroids; NSAIDs Anti-gout meds;
Diet: ---- Control obesity; Low purine;

Disease: Rheumatoid Arthritis Osteo-Arthritis Gouty Arthritis

Description:  A type of arthritis;  Also known as degenerative joint  Most painful type that occurs
 An autoimmune condition that causes disease; mostly during nighttime;
inflammation of joint, specifically the  Affects weight-bearing joints;  Intensifies 4-24 hours;
synovium (lining of the joints);  Most common type;  Type of arthritis that is
 Body immune system attracts the joints;  (-) inflammation, localized; caused by excessive
 No known cure, difficult to diagnose due accumulation of uric acid in
to other similar conditions  leads to the blood;
joint and bone problems (e.g.,
contractures and deformities);
 Systemic 
o Bilateral;
o Symmetrical;
 Affects all joints 
o But initially small joints of
hands and toes;

Cause: Direct cause: Risk factors: Risk factors:

 Unknown;  Genetics;  Excessive intake of purine-

 Old age: rich foods:
Risk factors: o 40 years old and above; o Internal organ
o Mostly men; meats (liver,
 More common in young women (20-40  Overweight / obesity; intestines, sweat
years old);  Repetitive joint stress, trauma, bread [pancreas],
 Thin and underweight women; injuries; red meats);
 Genetics and hormones;  Strenuous jobs (e.g., prolonged o Sea foods
standing); (anchovies, tuna,
sardines, shells);
o Alcoholic
beverages;
o Fruit juices and
sodas (high
fructose, corn
syrup);
 Medications:
 o Cocktail
neoplastics
(chemotherapeutic
drugs);
o Immunosuppressa
nt (e.g.,
cyclophosphamide)
;
o Aspirin;
o Diuretics;
o Niacin;
 Kidney problems;
 Dehydration  leads to
solidification of urate crystals;

Pathophysiology Stages of Rheumatoid Arthritis: Disease Process: Disease Process:

:
1. Synovitis –  Wear and tear   Altered purine metabolism
a. Description:  Cartilage erosion  
i. Inflammation of the  Bones will rub together   Excessive accumulation of
synovium that  Bone/cartilage outgrowth ; uric acid in the blood
produces synovial  Osteophyte / node formation (hyperuricemia) 
fluid; (“bone spurs”);  Uric acid solidify and form
2. Pannus formation – into needle-like crystals
a. Pannus grows and destroys known as tophi;
the cartilage;  Location of tophi formation –
3. Ankylosis – o Great big toe;
a. Description: o Helix of ear;
i. Deformities o Elbows;
affecting the o Knee;
metacarpophalange
al joints (knuckles);
b. Types –
i. Fibrous ankylosis;
ii. Bony ankylosis;

Signs and  5S –  Sunrise pain/stiffness <30  Arthralgia (joint pain) –

Symptoms: o Sunrise pain / stiffness in the minutes; o Sudden, intense,
morning >30 minutes (early  Crepitus (“cracking/crackling seldom attacks;
sign); sound”); o NC: put bed cradle
o Soft, swollen, warm, tender  Tenderness only when touching and foot board;
joints; the joint site (no warm, no  Redness and swelling
o Symmetrical (bilateral); swelling); joints;
o Systemic (keratoconjunctivitis,  Bony outgrowth (osteophytes) –  Soft, warm, tender joints;
anemia, fatigue, lungs and o Bouchard’s nodes:  Limited range of motion;
cardio symptoms);  Affects
o SPA (synovitis, pannus proximal
formation, ankylosis); interphalange
 Deformities due to bony ankylosis – al joints (PIP);
o Ulnar drift / ulnar deviation: o Heberden’s nodes:
 A deformity of the  Affects distal
hands that occurs interphalange
when al joints (DIP);
metacarpophalange  Late sign;
al (MCP) joints or
“knuckle bones”
become swollen and
cause the fingers to
bend abnormally
towards the ulna
(“pinky finger”);
 Z thumb;
o Swan neck deformity:
 Characterized by
hyperextension of
the proximal
interphalangeal
joints, and;
 Flexion/bending of
the distal
interphalangeal
joints;
o Boutonniere / “button hole”
deformity:
 Characterized by
flexion/bending of
the proximal
 interphalangeal
joints which “cannot
be straightened;
 Other systemic manifestations –
o Keratoconjunctivitis (late in RA):
o Anemia;
o Cock-up toe deformity:
 Also known as hallux
extensus;
 May occur
congenitally;
 May occur due to
injury or over
stretching of the
tendons of the toes
from activities such
as ballet;
 Can also be due to
neurologic conditions;
 Affects the big toe;

Diagnostics:  Blood tests –

o (+) rheumatoid factor;
o (+) ESR, C-reactive protein;
 X-ray –
o Will show joint deformities;

Medical Pharmacologic: Pharmacologic: Pharmacologic:

Management:
 NSAIDs  to decrease inflammation and  Intra-articular corticosteroid  To lower uric acid –
pain: injections: o Probenicid;
o NC: o Administered directly o Allopurinol;
 Watch out for GI into joints; o Colchicine;
upset; o Localized effect, reduce  To relieve pain –
 Take with foods; inflammation of o NSAIDs –
o Examples: tendons, and joints;  Ibuprofe
 Ibuprofen; o Best mode of treatment; n
 Naproxen;  Glucosamine with chondroitin:  Naproxe
 Diclofenac; o Supplement; n
 Corticosteroids  reduce inflammation: o Decreases the signs
o S/sx: and symptoms and See table below for details;
 Patient will improves joint functions;
experience weight  Pain medications:
gain; o NSAIDs 
 Hyperglycemia;  Provide pain
 Weak, brittle skin and relief, long-
nails; term
 Hair growth management;
(hirsutism);  MOA: blocks
 Bruising; enzymes
o Best routes: responsible
 PO; for pain and
 IM; swelling;
 Intra – articular  Examples –
(directly to joints); ibuprofen,
o Examples: naproxen,
 Prednisone; diclofenac;
 Dexamethosone;
 Methylprednisone;
 Triamcinolome;
 Disease-modifying anti-rheumatic
drugs (DMARDs)  suppresses the
immune system:
o Adverse effects:
 Immunosuppression
 cancer;
o MOA:
 Slows the destruction
of the joints;
o Examples:
 Hydroxychloriquine
(watch out for visual
changes, retinal
damage);
 Leflunomide;
 Sulfasalazine;
 Methotrexate;
  Methotrexate –
o NC:
 Monitor liver function;
 Avoid alcohol;
 Risk for infections;
 GIT side effects;
 Contraindicated in
pregnancy;
 Prednisone –
o NC:
 Should not be
abruptly
discontinued;
 Weight gain and fluid
retention are
common side effects;
 Increase risk of
cataracts and
glaucoma;
 Can lead to bone
density loss;
 Taken with food;

Surgery –

 Goal:
o Joint replacement, particularly
the synovium;
 Synovectomy:
o Removal of the synovium;
 Arthrodesis:
o Remaining joints are fused;
o Joints are reduced and bones
are fused with bone graft;

Nursing Swollen and inflamed joints: Health Education: Health Education:

Management:
 Advise to rest the joints using splints   Rest painful joints during  Avoidance of purine-rich
o No exercises, and; attacks; foods and certain
o No movements, especially  Educate the patient about the use medications;
during flare ups; of assistive devices;  Consume plenty of fluids (2-3
 Heat therapy   Lifestyle and home modifications L per day);
o 10-15 minutes – addresses –  Bed rest during attacks with
stiffness; o Clutter-free extremity on a cradle or
o Advise to take warm showers environment; footboard;
in the evening or upon o Remove carpets / throw  Elevate the affected joint;
awakening in the morning; rugs;  Applying cold compress >
o Examples – heating pads, o Raised toilet seats; warm compress;
warm compresses; o Install railings;
 Cold therapy (as needed)   Physical therapy and exercise
o 15-20 minutes – to address the (e.g., use of resistance bands,
pain and inflammation; water exercise) –
o To improve muscle
During flare ups: strength;
o Lose weight;
 Patient must rest the inflamed joints;
 Avoid position of extreme flexion;

Health education:

 Educate the patient about the

importance of exercise and physical
activity  to decrease fatigue, improve
muscle strength, and prevent contraction,
such as:
o Range-of-motion exercises;
o Low to mild impact exercises
–
 Walking;
 Swimming;
 Stationary bike riding;
 Requires multidisciplinary approach
(physical, nutritional, occupational);
 Monitor for signs of anemia;
o Iron supplementation;
 During pregnancy –
 o Pregnant women may
experience temporary relief
from RA symptoms;
o RA medications are safe for
breastfeeding;

Medications for Gouty Arthritis:

Name Used for Action Vital Information

Probenecid Lowering the serum uric acid level; Blocks uric acid reabsorption in the Salicylates (aspirin) antagonize
kidneys; this drug;

Fluid intake should be

increased;

Taken on an empty stomach;

Avoid alcohol;

Allopurinol (Zyloprim) Prevention of future gout attacks; Xanthine oxidase inhibitor  inhibits Fluid intake should be
uric acid production  lowering uric increased;
For chronic tophaceous gouty arthritis; acid levels in the blood;
Taken orally once a day, just
May be taken with colchicine or any Also known as urate-lowering therapy after eating with a full glass of
other NSAIDs; (ULT); water;

It does not relieve acute pain; Avoid alcohol;

SE:
headache, dizziness, changes in
sense of taste, rashes, visual
changes or disturbance;

Nursing Interventions:

Advise patient to have regular

eye exams;

Regular liver function tests;

Avoid anything with Vitamin C

as this actually increases the risk
of kidney stone formation;

Inform the patient to avoid

driving or operating heavy
machinery;

Long-term treatment and

prevention of GA, and if taken
regularly, can prevent gout
attacks;

Colchicine Prevention of gout attacks; Prevents inflammation due to urate Watch for GIT signs and
crystals deposition; symptoms;

Avoid alcohol;

Colchicine toxicity  greyish lips;

BONE DISEASES  Flat bones –
o Examples:
Functions of the Bones:
 Skull;
 Provides body framework;  Ribs;
 Allows movements and motion;  Scapulae;
 Protects and supports vital organs;  Sternum;
 Produces blood cells (rbc, wbc, platelet) by the red Parts of the Bones:
bone marrow;
 Storage for minerals, fats, and lipids;  Outside  compact;
 Inside  spongy;
Types of Bones:
Bone Cells:
 Long bones –
o Contains most of the bone marrow;  Osteoblast –
o Examples: o Breaks down the bone (bone
 Femur; resorption);
 Humerus; o Releases calcium from bone to blood 
 Short bones – hypercalcemia;
o Examples: o Makes the bone weak;
 Carpals;  Osteoclasts –
 Tarsals; o Builds the bone by absorbing calcium
 Irregular bones – from blood to bone  hypocalcemia;
o Examples: o Makes the bone strong;
 Spine (vertebrae);
Age of Peak Bone Mass:
 Sacrum;
 Coccyx;  30 years old;

Disease: Osteoporosis Fractures Compartment Syndrome

Description: Overview: Overview: Overview:

 Characterized by decrease bone  A complete or incomplete  Characterized by a painful

mass or density; disturbance in the progression of buildup of pressure around the
 A condition where the bones are bone structure; muscles;
becoming abnormally thin, weak,  May occur after severe injuries
frail, fragile, and brittle, where bones or as a surgery complication;
cannot withstand normal stress;  A medical emergency;
 This leads to pathologic bone fractures;

Common Sites of Fractures:

 Spine;
 Hips;
 Wrist;
o Colle’s fracture – fracture of
the wrist;

Cause: Exact cause: Risk Factors:

 Unknown;  Edema;
 Hemorrhage;
Risk factors:  Crushed injuries;
 Burns;
 Calcium and Vitamin D deficiency:  Casts;
o Recommended dietary intake  Fixation;
–  Traction;
 Adult – 1,200 mg;
 Pregnant – 1,500
mg;
o Sources –
 Milk;
  Dairy products
(e.g., cheese);
 Fish (e.g., salmon,
anchovies,
sardines);
 Eggs;
 Meat;
 Broccoli;
 Age (old):
o >30 years old;
o Post-menopausal women;
 Lifestyle (sedentary);
o Lacks exercise;
o Immobile;
o Alcoholic;
o Smoker;
o Excessive coffee drinkers;
 Caucasians and Asian women;
 Inherited (genetics);
 Underweight (BMI <19);
 Malnutrition
 + Medications:
o NSAIDs, aspirin;
o Corticosteroids > 3 months;
o Anticonvulsants;

Pathophysiology: Types of Osteoporosis: Types of Fractures: Disease Process:

 Type 1  menopause  due to  Open/compound   Anything that causes ⬆️

estrogen deficiency; o (+) skin involvement; pressure build up in one or more
 Type 2  senile type  due to o At ⬆️ risk of infection; compartments within the muscle
calcium deficiency;  Closed simple  and fascia 
o (-) skin involvement;  Blood flow is cut off 
Disease Process:  Comminuted   Tissue ischemia (d/t hypoxia) 
o Has >3 fragments/splinters  If unresolved in 4-6 hours 
 ⬆️ osteoclast activity  of the fractured bone;  Irreversible total loss of
 ⬆️ osteoblast activity   Transverse  functions;
 ⬆️ bone mass  o Horizontal crack or break
 Loss of spongy bone that contains red across the bone shaft;
marrow (trabeculae)   Oblique 
 Very fragile bone  o Slanting/diagonal;
 Fractures, kyphosis, ⬆️ height;  Spiral 
o Spins/twists around the
bone shaft;
 Complete 
o Across the bone shaft;
 Incomplete 
o Midway/halfway the bone
shaft;
 Avulsion 
o Bone and/or muscle tearing
or separation;
 Compressed 
o Crushed between two
bones;
 Impacted 
o Bone is forced into another
bone;
 Pathological fracture 
o Secondary to a
disease/condition;
 Depressed 
o Inward pressing deformity;
 Greenstick 
o Common in pedia;
o Incomplete fracture;
o The bone/s are either
cracked or bent;
o Occurs in 2 adjacent bones
(e.g., radius and ulna, tibia
and fibula);

Stages of Healing:

1. Stage 1 – hematoma formation:

a. 1-2 days from injury;
 b. Bleeding into the
injured site (watch out
for compartment
syndrome);
2. Stage 2 – fibrocartilagenous
formation:
a. 3-14 days after injury;
b. Granulation tissue
forms;
c. Reconnection of bones
begin;
d. Still not strong
enough to bear
weight;
3. Stage 3 – bony callus
formation (ossification):
a. 3-4 weeks from injury;
b. Mature bone begins
replacing callus;
4. Stage 4 – remodelling:
a. Months to years;
b. Compact bone
replaces spongy bone;

Signs and Manifestations: Manifestations: Manifestations:

Symptoms:
 Asymptomatic at early stages;  Pain and bruising at the site of  7Ps 
 Pathologic fractures, commonly in – injury; o Pain (early sign):
o Spine;  Limited / restricted movement;  Intense,
o Hips;  Visible deformity / odd progressive;
o Wrists; appearance  shortening of the  Active
 Rounding of the upper back – affected limb; movement;
o “Hunch back” appearance  Crepitus;  Passive
or kyphosis  severe  Redness and swelling (edema) movement;
deformity of the upper spine  can lead compartment o Pallor;
 dowager’s hump; syndrome; o Paresthesia;
o Painless; o Paralysis (late sign);
 Loss of height  2-3 inches of the Post Fracture: o Pulselessness;
young adult height; o Poikilothermia;
 Low back, hip, and neck pain on  Pain; o Pressure (intra-
palpation or ay activities that puts  Pallor; compartmental
pressure on the bones;  Pulselessness; pressure – normal: 0-
8 mmHg);
 Paresthesia;
 Does not respond to pain
 Paralysis;
medications;
 Pressure;
 Volkmann contracture –
 Poikilothermia;
o Also called “claw
hand”;
Intracapsular hip fracture  leg on
o As a result of
the affected side typically appears
compartment
shorter;
syndrome;
o No movement;
Fracture of the femur neck 
 Notify the physician at once;
involved limb appears shorter,
drawn inward (adducted), and
excessively rotated
Diagnostics: Bone density test / scan:

 Dual energy x-ray absorptiometry

(DEXA) scan:
o Description –
 Low-dose x-ray
that checks the
spongy bone
density;
 Measures the
mineral content
of the bones,
particularly
calcium;
 No special
preparation
needed;
o NC:
 Avoidance of
anything that has
calcium 24 hours
 before the
procedure;

Complications:  Osteomyelitis: Rhabdomyolysis  release of cell

 contents into the blood, including
myoglobin  tubular obstruction in
 Bone infection;
the kidneys  kidney damage 
 Caused by Staph. aureus; kidney failure;

Compartment Syndrome  see

next;

Medical Pharmacologic: Surgical Management: Surgical Management:

Management:
 Calcium and Vitamin D supplement;  Open reduction internal fixation;  Fasciotomy;
 Bisphosphonates:  Open reduction external fixation;  Amputation;
o Purpose –
 To decrease bone
breakdown;
o MOA –
 Limits the life span
of the osteoclasts;
 Prolongs the life
span of the
osteoblasts;
o Usually ends with “dronates”
–
 Alendronates;
 Ibandronates;
 Risedronates;
o Also –
 Fosamax;
 Boniva;
 Actonel;
o Nursing implications in
administering medications –
 Give meds 1 hour
before
breakfasts;
 Never give with
other meds and
foods;
 Full glass of
water 8 oz;
 Continue taking
Ca+ supplement;
 Be particular
because the
medication can
cause GI upset
and inflame the
esophagus;
 Instruct the patient
to avoid lying
down;
 Promote sit/upright
position 30
(fosamax, actonel)
– 60 minutes
(boniva);
 Assess renal
function;
 Assess for signs of
hypocalcemia;
 Evaluate flu-like
symptoms - acute
phase reaction;
 Calcitonin –
o
 Hormone replacement therapy (HRT)
–
o Purpose:
 For post
menopausal
women due to ⬆️
estrogen level;
  Short-term
therapy;
 Given orally or
injection;
 Reduces the risk of
osteoporosis
(prevention) by
preserving bone
mineral density
without the
estrogenic effects
on the uterus;
o MOA:
 Supplements
estrogen  ⬆️
osteoblast activity;
o Example:
 Raloxifene
(Evista);
o Side effects:
 Blood thickens 
deep vein
thrombosis, CVa,
MI, pulmonary
embolism;

Nursing Health Education: Nursing Interventions: Immediate Intervention:

Management:
 Raising awareness about increasing  Assessing for the  Place the extremity at heart
consumption of calcium and Vitamin neurovascular status: level (not above the heart level);
D-rich foods; o Capillary refill;  Open the cast or splint;
 Promote weigh-bearing exercises; o Movement;  Loosen or remove restrictive
 Lifestyle and home modification o Pulses; clothing;
exercises: o Warmth;  Avoid using cold compress
o Clutter free;  Immobilize the fractured (this can cause vasoconstriction
o Put hand rails; extremity  use of splints above which can worsen compartment
and below; syndrome);
 Stop the bleeding by putting  Notify the physician
pressure with use of a sterile immediately;
gauze / clean cloth  to prevent
⬆️ risk of infection;
 Elevate the extremity with 1 or
2 pillows to promote venous
return  reduce swelling,
compartment syndrome;
 Apply ice wrap in a towel near
the fractured area;
 Place the patient on NPO
status until evaluated by HCP;
 Pain managements  give
meds:
o To provide relief;
o Then assess response
–
 With
response 
fracture;
 No response

compartment
syndrome
(does not
respond to
steroids);
 Benign Malignant
ONCOLOGY NURSING Growth Rate:
Differentiation:
Slow
Well-differentiated;
Rapid
Poorly undifferentiated;
Capsule: (+); (-);
OVERVIEW Location: Localized; Metastasizing;
Growth Type: Expansive; Infiltrative, invasive;
Cell and Tissue Abnormalities: Recurrence: Rare; ⬆️

 Hyperplasia –
o Increase in the number of cells in a Routes of Metastasis:
normal arrangement in a tissue or an
 Cerebrospinal fluid (CSF);
organ due to a higher rate of cell
 Blood –
division;
o Fastest route;
o Example – benign prostatic hyperplasia;
 Lymph nodes –
 Metaplasia –
o Most common route;
o Metaplasia is the process where one
type of mature cell is replaced by Sites of Metastasis:
another type of mature cell that is not
normally present in that tissue;  Brain;
o This change is often a response to  Bones;
chronic irritation or inflammation and can  Liver;
sometimes be reversible;  Lungs;
o Example – in chronic smoking, the
Classification by Tissue Types:
normal ciliated columnar epithelial cells
in the respiratory tract can be replaced  Carcinoma –
by squamous epithelial cells (squamous o Originates from the epithelial layer of
metaplasia); cells that form the lining of external
 Anaplasia – parts of the body or the internal linings
o The presence of a completely of organs within the body;
undifferentiated tumor cells that do not o Accounts for 80-90 percent of all cases
resemble cells of their origin; since epithelial tissues are most
o Example – anaplastic thyroid carcinoma; abundantly found in the body;
 Dysplasia – o Usually affects organs and glands
o Abnormal changes in the shape, size, capable of secretions including
and organization of mature cells; breasts, lungs, bladder, colon, and
o Usually associated with cancerous or prostate;
pre-cancerous growth and is often  Sarcoma –
reversible by removal of the inciting o Originate in connective and
stimulus or eliminated by removing the supportive tissues including muscles,
entire diseased organ; bones, cartilage, and fat;
o Example – cervical dysplasia; o Most common – bone cancer
 Neoplasia – (osteosarcoma);
o The process of abnormal and  Myeloma –
uncontrolled cell growth which can lead o Originate in the plasma cells of the
to the formation of a tumor; bone marrow;
o It can be benign or malignant; o Most common – multiple myeloma;
o Examples – benign neoplasm (e.g.,
lipoma); malignant neoplasms (e.g.,
breast cancer or lung cancer);  Leukemia –
o Cancers that affect the bone marrow
which is the site for blood production;
 Lymphoma –
NEOPLASM o Cancers of the lymphatic system;
o Affects the lymph nodes at specific
Benign vs. Malignant: sites like stomach, brain, intestines, etc.
Warning Signs:  Procedures –
o Excisional biopsy:
 Change in bowel / bladder habits;  Complete removal of the entire
o Testicular cancer; lesion;
o Prostate cancer; o Incisional biopsy:
o Ovarian cancer;  Removal of a wedge of
 A sore that does not heal; suspected tissue from a larger
o Mouth cancer; mass;
o Fine-needle aspiration:
 Unusual bleeding discharges;  Aspiration of cells;
o Cervical cancer:  Categories –
 Signs - o Grading:
 Bleeding after sex;  Type of cells;
 ⬆️ menses; o Staging:
 Bleeding in between  Focuses on the tumor;
menses;
 Cause – TNM Classification:
 HPV - #1;
 Tumor – size of the tumor:
 HSV;
o T0 – no evidence as primary tumor;
 Risk factors –
o Tis – carcinoma in situ;
 Multiple sexual
o T1 – <3 cm;
partners;
o T2 – >3 cm to <5 cm;
 Early age of sex;
o T3 – >5 cm to < 7 cm;
 Smoking;
o T4 – >7 cm;
 Low social economic
 Nodes – number of nodes involved:
status;
o Nx – regional lymph nodes cannot be
 Immunosuppression;
evaluated;
 High-risked sexual
o N0 – no regional lymph node
partners;
involvement;
 Thickening of a lump in the breast / elsewhere; o N1 – involvement of 1-3 regional nodes;
o Breast cancer; o N 2 – involvement of 4-6 regional nodes;
 Indigestion and dysphagia; o N3 – involvement of 7+ regional nodes;
o Laryngeal cancer;  Metastasis –
o Esophageal cancer; o M0 – no distant metastasis;
o Stomach cancer; o 1 – distant metastasis;
o Colon cancer;
Chemotherapy:
 Obvious change in warts / moles;
o Skin cancer (e.g., melanoma – most  MOA –
dangerous); o Kills rapidly dividing cells, including:
 Cancer;
 Nagging cough / hoarseness;  Hair follicles;
o Lung cancer;  Skin;
 Unexplained anemia;  GIT lining, mucosa;
o Leukemia;  Bone marrow 
o Multiple myeloma; myelosuppression 
 Sudden, unexplained weight loss; pancytopenia;

Biopsy:
 Types –
 Purpose –
o To confirm; Drug Mechanism of Action Examples
o To distinguish; Alkylating Alkylating agents affect Cyclophosphamide;
agents all rapidly proliferating Ifosfamide;
o To determine management; cells by interfering with Cisplastin;
 DNA; they may kill Carboplatin; Temporary only - will grow 6
dividing cells in all Oxaliplatin;
phases of the cell
weeks to 6 months after the last
cycle and may also kill dose of chemotherapy;
nondividing cells;
o Weak, tearing skin, brittle nails;
Anti- Interfere with DNA and Aminopterin; o Nausea and vomiting, diarrhea:
metabolites RNA by acting as a Cytarabine;  Most common;
substitute for the Fluorouracil;
normal building Methothrexate; o Pancytopenia 
blocks of RNA and  Fatigue;
DNA.
 Risk for infection;
Antimetabolites act  Bleeding;
during the S phase of
the cell cycle,  Management –
contributing to cell o For nausea and vomiting:
destruction or
preventing cell
 Anti-emetics, as prescribed, 30-
replication. They’re 60 minutes before
most effective against chemotherapy:
rapidly proliferating
cancers;  Plasil;
 Domperidone;
Anti-tumor Antineoplastic antibiotic -mycin;
antibiotics agents interfere with  Dramamine;
one or more stages of Bleomycin;  Onoansetron (zofran);
the synthesis of RNA, Dactinomycin;
DNA, or both, Mitomycin-C; o For alopecia:
preventing normal cell Mitoxantrone;  Advise the patient to wear
growth and
reproduction
anything to cover the head;

Anthra-cycline A type of anti-tumor -bicin; Radiation Therapy:

antibiotics that interfere
with enzymes involved Daunorobicin;  MOA –
in copying DNA during Doxorubicin;
cell cycle. They bind Epirubicin; o Kills the cancer cells/tumor by reducing
with DNA so it cannot Idarubicin; their size, thereby relieving obstruction;
make copies of itself, Valrubicin;
and a cell cannot
 2 main types –
reproduce. o Brachytherapy:
 Direct contact with the radiation;
Mitotic Miotic inhibitors -taxel;
inhibitors interfere with cell o Internal radiation therapy:
division or mitosis Cabazitaxel;  Sealed –
during the M phase of Docetaxel;
the cell cycle. Nab-paclitaxel;  Radioactive source is
Paclitaxel; implanted into the
-stine; patient’s body;
 Localized;
Vinblastine;
Vincristine;
 Example indication:
cervical cancer;
Topoisomerase Inhibits Irinotecan;  Unsealed –
inhibitors topoisomerases, Etoposide;
enzymes that manage  Radioactive substance
the DNA structure is injected or given
during replication. This
leads to DNA breakage orally to the patient;
and cell death.  Systemic;
Hormonal Block or alter Tamoxifen (estrogen  Example indication:
agents hormone levels in the receptor antagonist); leukemia;
body, which can slow
o Teletherapy;
or stop the growth of Aromatase inhibitors
hormone-sensitive (e.g., anastrozole);  Indirect contact with the
tumors; radiation;
Androgen receptor
antagonists (e.g.,  Beam of high energy rays is
enzalutamide); directed to the patient’s body
area;
 Side effects –
o Alopecia:
  Radiation oncologist mark  Management:
specific location with semi- o Never wash semi-permanent ink;
permanent ink; o Avoid exposure to direct sunlight;
 Outpatient, 15-30 minutes per o Avoid constrictive clothing;
session; o Avoid extreme temperatures;
 5 days per week; o Avoid chemicals especially oils;
 2 to 7 weeks; o Inform the patient that the procedure is
 S/sx: painless;
 Alopecia; o Inform the patient can verbalize
 Stomatitis (ulceration of concerns during procedure;
the mucous
membranes); Pain Control:
 Xerostomia (dry mouth);  Causes of pain –
 Headache; o Bone destruction;
o External radiation therapy; o Obstruction of an organ;
 Factors affecting exposure – o Compression of peripheral nerves;
o Shielding: o Infiltration, distension of tissue;
 By wearing of lead shield or o Inflammation, necrosis;
lead apron; o Psychological factors;
 Put a radiation sign;  Interventions –
 Do not remove dosimeter film o Develop a pain management program
badge; with the healthcare team;
o Time: o Administer oral preparations if
 Limit to 6 visits/shift, or 30 possible if they provide adequate relief
minutes/shift = 5 minutes/visit; of pain; transdermal or trans-mucosal
o Distance: route may also be prescribed;
 Provide safe distance away o Mild or moderate pain may be treated
from the radiation source: 3-6 with salicylates, acetaminophen, or
feet away; NSAIDs;
 Not allowed – o Severe pain is treated with opioids;
 Pregnant; o Neuropathic pain may be treated with
 Immunosuppressed; a variety of anticonvulsants and
 Newly vaccinated; antidepressants;
 Children <16 years old; o Subcutaneous and IV infusions of
 Prepare the following – opioids provide rapid pain relief;
 Long-handled forceps; o Monitor vital signs and side effects of
 Lead bin/container; medications;
 Side effects – o Provide non-pharmacologic
o Site-specific; techniques of pain, such as relaxation,
o Fatigue – most common; guided imagery, massage, and heat-cold
o Radiation burns (dermatitis); applications;
Most Common Cancers to Men and Women:
Breast Cancer Prostate Cancer
Description:  Abnormal proliferation of cancer cells in the breast  Abnormal proliferation of cancer cells in the prostate;
(upper outer quadrant);  most common cancer in males;
 Associated with ⬆️ estrogen exposure;  Associated with ⬆️ testosterone exposure;

Cause/Risk Factors: Risk Factors: Risk Factors:

 Late menopause;  Sexually transmitted diseases;

 Obesity;  Testosterone;
 Nulliparity;  African-Americans;
 Genetics;  Forty and up;
 Forty and up, ⬆️ fat diet, red meat;  Fat diet, including red meats;
 Oral contraceptions;
 Early menarche;

Signs and Symptoms: Manifestations: Manifestations:

 Asymmetrical breasts (obvious), saggy;  Asymptomatic at early stage – slow growing;

 Venous prominence (⬆️ vascularity);  Peri-anal and rectal pain;
 Orange-pale skin (peau de orange);  Urinary obstruction;
 Nipple retraction;  Hematuria;
 Enlargement of the prostate;
 Dysuria;
 Low back pain (late stage) – will compress the
surrounding pelvic bone;

Common Metastatic  Bone;  Bone (most common, alongside lymph nodes);

Sites:  Brain (less common);  Brain;
 Lungs;  Lungs;
 Liver;  Liver;

Diagnostics: Breast Self-Examination: Prostate Specific Antigen (PSA):

 Purpose –  Protein produced by the prostate gland;

o For early detection of mass/lumps in the  Normal: 0.2-4 ng/mL;
breasts;
o For baseline and comparison: Digital Rectal Examination:
 Age  20 years old, monthly;
 Regular  7 days after the  Part of regular health check-up;
start of menses;  Baseline:
 Irregular / TAHBSO patient  o >40 years old, annually;
same day every month;  To ass the size, shape, and consistency of the prostate
 Pre-menopausal women – gland;
immediately after menstrual
period; Prostate biopsy:
 Inspection –
o Check for previous changes from month  Confirmatory;
prior;
o Check for irregularities, skin irritation,
discoloration, redness, and dimpling;
o Check for mass/lumps under the skin;
o Check for unusual nipple changes, such
as retraction (pinkish) and discharges
(foul-smelling;
 Pattern of palpation –
o From outer to inner;
 Steps –
o Examine your breasts in the shower;
o Examine your breasts in the mirror with
hands on hips;
o Raise arms and examine breasts;
o While looking at the mirror, look for any
signs of fluid coming out of one or both
nipples;
o Lying down –
 Place one arm over the head
and a pillow or folded towel
under the shoulder;
 Using the right hand, feel the
left breast, and then the left
hand to feel for the right breast;
 Use a firm, smooth touch with
the first few finger pads of the
 hand, keeping the fingers flat
and together;
 Press down with the fingers
and move them in circular
motion that’s about the size of
a quarter (or an inch around);
 Cover the entire breast;
 Start in the underarm area and
move the fingers downward
little by little until they are
below the breast. Then move
the fingers slightly toward the
middle and slowly move back
up. Go up and down until you
cover the whole area;

Health Worker Breast Exam:

 Baseline – 20-39 years old;

 Frequency –
o Every 3 years;
o >40: annually;

Diagnostic Procedures:
 Mammography –
o Low dose X-ray examination of the
breastu used to detect tumors before
they can be felt;
o Baseline:
 Once – 35-39 years old;
 Annually – 40 years and up;
o NI:
 Avoid powder, deodorant, and
lotion;
 Breast biopsy –
o Confirmatory test;

Management: Surgical Management: Active Surveillance:

 Lumpectomy – removal of:  For low-risk prostate cancer that is not causing
o Tumor; symptoms or showing signs of aggression;
o Lymph node dissection may also be  Regular monitoring with PSA tests, digital rectal exams,
performed; ad periodic biopsies;
 Simple mastectomy – removal of:
o Whole breast (including nipple and Surgical Management:
areola);
o Lymph nodes optional;  Radical prostatectomy –
 Partial mastectomy – removal of: o Removal of the prostate gland and some
o Portion of the breast tissue, including the surrounding tissue;
tumor and some surrounding tissue; o Potential side effect:
 Total mastectomy – removal of:  Urinary incontinence;
o Similar to simple mastectomy;  Erectile dysfunction;
 Radical mastectomy (halstead procedure with
skin grafting) – removal of: Radiation Therapy:
o Whole breast:
o Lymph nodes;  External beam radiation therapy and brachytherapy;
o Pectoralis major and minor muscle;  For localized prostate cancer or cancer that has
 Modified radical mastectomy – removal of: recurred after initial treatment;
o All except pectoralis minor as pocket for  NC – side effects:
artificial silicon breast implant; o Fatigue;
o Urinary issues;
Post-op Management: o Bowel problems;

o Prevent lymphedema / arm edema;

o Provide analgesic; Systemic Therapies:
o Semi-fowler’s;
o Encourage arm exercises;  Hormone therapy –
o Prevents testosterone from reaching cancer
Post-op Medications: cells or by reducing testosterone levels;
 Chemotherapy;
 Tamoxifen (nolvadex):  Immunotherapy;
o Indication –  Targeted therapy;
 Prevent recurrence of breast
cancer; Cryotherapy;
o Classification –
  Anti-estrogen medication;
o Route and frequency –
 Given orally, for a minimum of
5 years;
o Side effects –
 Vision changes  blindness
(advise regular, periodic eye
exam);
 Anorexia;
 Headache;
Cancers of the Reproductive System:
Ovarian Cancer Cervical Cancer Testicular Cancer
Description:  Grows very rapidly, spreads  May be pre-invasive or invasive:  Cancer that arises from germinal
fast, and is often bilateral; o Pre-invasive – limited to epithelium from the sperm-
 Metastasis occurs by: the cervix; producing germ cells or from non-
o Direct spread – organs o Invasive – in the cervix germinal epithelium structures in
in the pelvis; and other pelvic the testicles;
o Distal spread – through structures;  Occurs between the ages of 15-
lymphatic drainage, or  Metastasis usually is confined to 40 years;
peritoneal seeding; the pelvis, but distant metastasis
 Has higher mortality rate than occurs through lymphatic spread;
any other cancer of the female
reproductive system;

Cause/Risk Risk Factors: Risk Factors: Risk Factors:

Factors:
 Genetic (e.g., lynch syndrome or  HPV infection;  Cryptorchidism (undescended
hereditary nonpolyposis  Cigarette smoking, both active testicle);
colorectal cancer); and passive;  Family history;
 Family history;  Sexual behaviors –  Previous history of testicular
 ⬆️ with age, particularly after o Early intercourse (<17 cancer in one testicle;
menopause; years);  Age – 15 to 40 years old;
 Nulliparity, or pregnancy > 30 o Multiple sex partners;  HIV infection;
years old; o Male partner with multiple
 Use of hormone replacement sex partners;
therapy;
 Endometriosis;
 Obesity;
 Early menarche;

Signs and Manifestations: Manifestations: Manifestations:

Symptoms:
 Asymptomatic at early stages –  Painless vaginal post-menstrual  Painless testicular swelling
most women are diagnosed in and post-coital bleeding; occurs;
advanced stages;  Foul-smelling or sero-  “Dragging” or “pulling”
 Abdominal discomfort or sanguineous vaginal discharge; sensation is experienced in the
swelling;  Pelvic, lower back, leg, or groin scrotum;
 GI disturbances; pain;  Enlargement or change in the
 Dysfunctional vaginal bleeding;  Anorexia and weight loss; shape or texture of a testicle;
 Abdominal mass;  Leakage of urine and feces from  Palpable lymphadenopathy,
 ⬆️ tumor marker; the vagina; abdominal masses, and
 Dysuria; gynecomastia may indicate
 Hematuria; metastasis;
 Cytological changes on Pap test;  Late symptoms –
o Back pain;
o Bone pain;
o Respiratory symptoms;

Common  Direct spread –  Bone;  Bone;

Metastatic Sites: o Organs in the pelvis;  Brain;  Brain;
 Distal spread –  Lungs;  Lungs;
o Bone;  Liver;  Liver;
o Brain;
o Lungs;
o Liver;

Diagnostics: Pelvic Examination: Endocervical Curettage; Testicular Self-Examination:

 Physical exam to check for Loop Electrosurgical Excision  Timing –

abnormal masses or tenderness; Procedure; o Performed monthly;
o Same day each month;
Exploratory Laparotomy; Biopsy;  Steps –
o Best time is right after a
Transvaginal Ultrasound; warm shower;
o Gently lift each testicle.
Each one should feel like
an egg, firm but not hard,
and smooth with no
lumps;
o Using both hands, place
the middle fingers on the
underside of each testicle
and thumbs on top;
 o Gently roll the testicle
between the thumb and
fingers to feel for any
lumps, swelling, or mass;
o If you notice any changes
from 1 month to the next,
notify the doctor;

Ultrasound;

Radical Inguinal Orchiectomy:

 Performed instead of scrotal biopsy

to avoid the risk of spreading
cancer cells;
 This entails surgical removal of the
testicle to obtain a definitive
diagnosis;

Management: Surgical Management: Surgical Management: Surgical Management:

 Total abdominal hysterectomy  Conization –  Radical inguinal orchiectomy –

and bilateral salpingo- o Removal of cone- o The removal of the
oophorectomy (TAHBSO) with shaped piece of affected testis, spermatic
tumor debulking may be cervical tissue to treat cord, and regional lymph
necessary; pre-cancerous lesions; nodes;
o Allows the woman to  Unilateral orchiectomy;
External Radiation: retain reproductive
capacity; Pre-op Management:
 May be used if the tumor has o Risks of the procedure –
invaded other organs;  Hemorrhage;  Discuss reproduction, sexuality, and
 Intra-peritoneal radioisotopes  Uterine fertility information, and options with
may be instilled for stage 1 perforation; the client;
disease;  Incompetent  Identify reproductive options, such
cervix; as sperm storage, donor
Chemotherapy:  Cervical insemination, and adoption;
stenosis;
 Used postoperatively for most  Pre-term labor; Chemotherapy;
stages of ovarian cancer;  Hysterectomy –
 Intraperitoneal chemotherapy o Removal of the uterus Radiation Therapy;
involves the instillation of and cervix;
chemotherapy into the abdominal o Total – removal of the
cavity; uterus and cervix;
o Radical – removal of the
uterus, cervix, and
surrounding tissues, and
sometimes, ovaries;
o NI:
 Avoid sexual
intercourse
for 3-6 weeks,
as prescribed;
 Monitor for
vaginal
bleeding. More
than 1
saturated pad
per hour may
indicate
excessive
bleeding;
 Thrachelectomy –
o Removal of the cervix
and surrounding tissue,
while preserving the
uterus;
o Usually for early-stage
cancer;
 Pelvic exenteration –
o Removal of all pelvic
contents, including
bowel, vagina, and
bladder;
o A radical surgical
procedure performed for
recurrent cancer if no
evidence of tumor
 outside the pelvis and no
lymph node involvement
exist;
o Ileal conduit – if bladder
is removed;
o Colostomy – if bowel is
removed;

Non-Surgical Management:

 Chemotherapy;
 External radiation;
 Internal radiation implants (intra-
cavitary);
 Laster therapy;
Cancers of the Blood (Myeloma and Lymphoma):
Multiple Myeloma Hodgkin’s Lymphoma Non-Hodgkin’s Lymphoma
Description:  Malignant proliferation of  A malignancy of the lymph nodes  Similar to Hodgkin’s lymphoma,
plasma cells within the bone; that originates in a single lymph except in the absence of Reed-
 Excessive numbers of abnormal node or a chain of lymph nodes; Stenberg cells;
plasma cells invade the bone  Other immune cells are also
marrow and ultimately destroy affected, including T lymphocytes;
the bone;  Metastasis occurs to other,
 Invasion of the lymph nodes, adjacent lymph structures and
spleen, and liver occurs; eventually invades non-lymphoid
tissue;

Stages of Hodgkin’s Lymphoma:

 Stage I –
o 1 lymph node
involvement;
 Stage II –
o At least 2 or more
lymph nodes are involved
(unilateral);
o Diaphragm;

 Stage III –
o At least 2 or more
lymph nodes are involved
(bilateral);
 Stage IV –
o Widespread metastasis;

Pathophysiology: Disease Process: Disease Process: Disease Process:

 Abnormal plasma cells  rapid  B lymphocytes undergo  Lymphocytes (B-cells or T-cells

replication  infiltration of the malignant transformation  into [less common]) undergo
bone  bone marrow lymphomas called Reed- malignant transformation  into
suppression  ⬆️ production of Stenberg cells  causing lymphomas  causing
functional blood cells  anemia, uncontrolled proliferation in the uncontrolled proliferation in the
⬆️ bleeding, ⬆️ infection; lymph nodes  and formation of lymph nodes  and formation of
 Abnormal plasma cells  lymphoid tumors  lymphoid tumors  inflammation
production of abnormal inflammation  impairment of  impairment of normal
antibodies (Bence-Jones normal functions; functions;
proteins)  deposition in various
organs  organ damage 
organ failure (e.g., kidney failure);
 Abnormal plasma cells  ⬆️
osteoclast activity  ⬆️ bone
resorption  hypercalcemia, ⬆️
bone density  fractures and
bone pain;
 ⬆️ abnormal antibodies, ⬆️
functional WBC 
immunosuppression  ⬆️
infection;

Cause/Risk Risk Factors: Risk Factors:

Factors:
 Genetic;  Genetics;
 Environmental factors –  History of STD, especially Epstein-Barr Virus –
chemical exposure; o Infectious mononucleosis;
 Pre-existing conditions (e.g., o Also known as “kissing’s disease.”
monoclonal gammopathy of o Ultimately fatal if left untreated;
undetermined significance);  HIV/AIDS;
 Family history;  Age – 20 to 40 years old;
 Common in males;

Signs and Due to ⬆️ bone resorption: Presenting (Early) Signs:

Symptoms:
 Bone pain (esp. in the ribs,  Painless enlargement of the cervical lymph nodes (neck);
spine, and pelvis);
 Osteoporosis; Other Signs and Symptoms:
 Hypercalcemia;
 Spinal cord compression and  B symptoms – all must be present:
paraplegia; o Fever;
 o Unexplained weight loss;
Due to bone marrow suppression: o Night sweats;
 Hepatosplenomegaly;
 Anemia  weakness and  Anemia –
fatigue; o Malaise, fatigue, and weakness;
 Leukopenia  recurrent  Thrombocytopenia –
infections; o Easy bruising;
 Thrombocytopenia  bleeding; o Bleeding;

Due to organ damage r/t Bence-

Jones proteins (e.g., kidney failure):

 Hyperuricemia;
 Hypercalcemia;
 Fluid retention;
 Oliguria, anuria;
 Electrolyte imbalances;
 High blood pressure;

Due to ⬆️ Bence-Jones proteins:

 Hyperviscosity of the blood 
headache, dizziness, and blurred
vision;
 Immunosuppression;

Common Lymphatic vessels; Lymphatic vessels;

Metastatic Sites: Tonsils; Tonsils;
Adenoids; Adenoids;
Spleen; Spleen;
Bone Marrow; Bone Marrow;

Diagnostics: Blood Tests: Lymph Node Biopsy: Lymph Node Biopsy:

 Detects monoclonal proteins in  Confirms the presence of Reed-  Confirms the presence of
the blood; Stenberg cells, particularly in the lymphoma and rule out Reed-
 Measures serum calcium levels; cervical lymph nodes; Stenberg cells;
 Measures serum uric acid levels;
CT scans, X-rays: Bone Marrow Biopsy:
Urine Test:
 Positive enlargement of the liver  To determine if the lymphoma has
 Detects proteinuria due to and spleen; spread to the bone marrow;
presence of Bence-Jones
proteins; Lumbar Puncture:

Bone Marrow Tests:  To determine if the lymphoma has

affected the central nervous
 Bone marrow biopsy and bone system;
marrow aspiration –
o To test for the presence Blood Tests:
of myeloma cells;
 To rule out other conditions,
X-Ray, MRI, CT scan: including infections;

 Evaluates the extent of bone Imaging Tests:

problems linked with multiple
myeloma;  CT scan and MRI;
 Loo for signs of lymphoma in the
Staging: body;

 Stage I – less than or equal to 1

bone lesion;
 Stage II – more than 1 lesion, but
not as severe as stage III;
 Stage III – multiple bone lesions;

Management: Bone Marrow Transplant: Extensive External Radiation:

 Autologous bone marrow  For earlier stages (I and II) without mediastinal node involvement;
transplant –
o Blood-forming stem Chemotherapy:
cells are collected from
the patient’s blood;  Alongside radiation, for more extensive disease;
o High doses of
chemotherapy then are Stem Cell Transplantation:
given to destroy the
 patient’s diseased bone  High-dose chemotherapy followed by autologous or allogeneic stem cell
marrow; transplantation;
o Then, the stem cells
are put into the Supportive Care:
patient’s body;
o They travel to the  Monitor for side effects related to chemotherapy or radiation therapy;
bones and begin  Monitor for signs of infection and bleeding;
rebuilding bone  Discuss the possibility of sterility with the client receiving chemotherapy and/or
marrow; radiation, and inform the client of fertility options such as sperm
 Allogenic bone marrow
transplant –
o Stem cells from a
healthy donor;

Medications:

 Chemotherapy;
 Radiation Therapy:
o May be used if
myeloma cells form a
mas called
plasmacytoma;
o It can help control a
plasmacytoma that’s
causing pain or
destroying a bone;
 Steroids:
o To reduce inflammation
and control symptoms;
o Examples –
dexamethasone and
prednisone;
 Supportive care:
o Biphosphonates;
o Pain management;
o Renal support;
o Maintain neutropenic
and bleeding
precautions as
necessary;
o Monitor for signs of
bleeding, infection, and
skeletal fractures;
o ⬆️ fluid intake to at least
2 L/day;
Cancers of the Blood (Leukemia):
Acute Myeloid Leukemia Chronic Myeloid Leukemia Acute Lymphatic Leukemia Chronic Lymphatic
(AML) Leukemia
Description:  A type of blood cancer  Similar to AML;
that originates in the  But the myeloid cells are
bone marrow; typically more mature
 Characterized by the than AML, albeit still
rapid proliferation of abnormally functioning;
immature myeloid cells  Progresses slowly and
with abnormal function is often diagnosed in its
in the bone marrow; chronic phase;
 Know for its aggressive
nature and rapid
progression;

Pathophysiology: Disease Process: Disease Process:

 Mutation in the  Translocation between

hematopoietic stem chromosome 9 and 22
cells or early myeloid 
progenitor cells   Creation of an abnormal
 Production of chromosome called
immature myeloid cells Philadelphia (Ph)
that divides rapidly  chromosome 
 Accumulation of  Ph chromosome forms a
abnormal WBCs in the new gene called BCR-
bone marrow  ABL 
 Displacement of normal  BCR-ABL makes a
blood cells  protein that tells the
 Spills over to peripheral bone marrow to
blood; produce too many white
blood cells 
 Immature and
dysfunctional WBCs form

 Accumulates in the
bone marrow;

3 phases of CML:

 Chronic phase –
o Initial indolent
period;
o 5-6 years;
 Accelerated phase –
o Treatment
failure;
o Worsening
pancytopenia;
o Persistent
splenomegaly;
 Blast phase –
o Accumulation of
blasts in
extramedullary
sites (e.g.,
bone, CNS,
lymph nodes,
skin);
o Blasts in the
bone marrow >
20%;

Cause/Risk Risk Factors: Risk Factors:

Factors:
 Genetic mutations;  Exposure to high levels
 Exposure to radiation of radiation;
or chemotherapy (e.g.,  Long-term exposure to
previous cancer certain chemicals like
treatment); benzene;
 Chemical exposure  Genetic factor
(e.g., benzene); (Philadelphia
chromosome);
  Pre-existing blood
disorders (e.g.,
aplastic anemia);
 Genetic syndromes
(e.g., down syndrome
or fanconi anemia);

Signs and Manifestations: Manifestations:

Symptoms:
 Displacement of normal  Asymptomatic early on;
blood cells 
fatigue/weakness, Insidious onset of non-
frequent infections, specific symptoms:
easy
bruising/bleeding;  Displacement of normal
 Infection  fever; blood cells 
 Skin infiltration  fatigue/weakness,
leukemia cutis; frequent infections,
 Liver and spleen easy bruising/bleeding;
infiltration   Infection  fever;
hepatosplenomegaly   Skin infiltration 
abdominal discomfort; leukemia cutis;
 Bone marrow and  Liver and spleen
periosteal infiltration  infiltration 
bone pain, gouty hepatosplenomegaly 
arthritis; abdominal discomfort;
 Meningeal infiltration   Bone marrow and
cranial nerve palsies, periosteal infiltration 
headache, visual or bone pain, gouty
auditory symptoms, arthritis;
altered LOC, transient  Meningeal infiltration 
ischemic attack; cranial nerve palsies,
 Weight loss; headache, visual or
auditory symptoms,
altered LOC, transient
ischemic attack;
 Weight loss;

Common Bone; Bone;

Metastatic Sites: Brain; Brain;
Liver (including spleen); Liver (including spleen);
Lungs; Lungs;

Diagnostics: CBC and Peripheral Smear:

 Pancytopenia and presence of peripheral blasts

suggest acute leukemia;

Bone Marrow Examination:

 Presence of blasts;

Cytogenetic Analysis:

 Identifies chromosomal abnormalities associated with AML

or CML;

Molecular Testing:

 Detects specific genetic mutations;

Immunophenotyping:

 Flow cytometry to classify the leukemia cells based on

surface markers;

Management: For Medically Fit Patients: Asymptomatic Chronic

Phase:
 Induction
chemotherapy – initial  Tyrosine kinase
treatment to induce inhibitors –
remission; o First-line
treatment for
CML;
 Consolidation o Inhibits BCR-
chemotherapy – to ABL oncogene;
eradicate residual o Examples (-
leukemia to prevent tinib) -
relapse; imatinib,
 Allogeneic nilotinib,
hematopoietic stem dasatinib,
cell transplantation; bosutinib,
ponatinib);
For Medically Frail Patients:
Accelerated or Blast Phase
 Less intensive therapies; CML:

Supportive Care:  Allogeneic

hematopoietic stem cell
 Blood transfusions; transplantation;
 Antibiotics;
 Medications to manage Supportive Care:
symptoms and prevent
complications;  Blood transfusions;
 Antibiotics;
 Medications to manage
symptoms and prevent
complications;