Kathryn E Tasillo PT DPT Disclosure There is no relationship that could reasonably by viewed as creating a conflict of interest or the appearance of a conflict of interest that might bias the content of the presentation Nor is there any significant financial interest in any product instrume ID: 910523
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Slide1
Managing the Cancer Patient in the Acute Care Setting
Kathryn E. Tasillo, PT, DPT
Slide2Disclosure
There is no relationship that could reasonably by viewed as creating a conflict of interest, or the appearance of a conflict of interest, that might bias the content of the presentation. Nor is there any significant financial interest in any product, instrument, device, service or material discussed in the presentation, including the source of any third-party compensation related to the presentation.
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide3WHO WE ARE
Carolinas HealthCare System
has a unique story to share. Operating as a fully integrated system and
connecting and transforming
care delivery throughout the Carolinas, our overarching goal is to provide seamless access to coordinated, high quality healthcare – and provide that care
closer to where our patients live.
With
42 hospitals and 900+ care locations, the depth and breadth of services results in a full continuum of integrated care including:Prevention and general wellnessPrimary care at more than 180 locations Specialty care via several nationally recognized service lines Critical care with one of the largest virtual (e-ICU) programs in the nationContinuing care including home health, skilled nursing, hospice, palliative care centers, inpatient/outpatient rehab, and long-term acute care hospital
""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide4AT-A-GLANCE
42 hospitals
and
900+ care locations
in North Carolina, South Carolina and GeorgiaMore than 7,800 licensed bedsMore than 11 million
patient encounters in 2013
3,000+
system-employed physicians, 14,000+ nurses and more than 60,000 employees$1.5 billion in community benefit in 2013More than $8 billion in annual revenueThe region’s only Level I trauma center One of five academic medical centers in North CarolinaOne
of the largest HIT and EMR systems in the country"Managing "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide5WHERE WE ARE
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide6Learning Objectives
General Overview of Cancer Statistics and Basics
Tests/Treatments/Side Effects/Lab Values
Special Patient Populations
Rehabilitation Considerations How to Handle End of Life Issues across Continuum of Care
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide7Cancer Statistics1
The National Cancer Institute estimates that approximately 14.5 million Americans with a history of cancer were alive in 2014 and is expected to be almost 19 million by 2024.
About 1,685,210 new cancer cases are expected to be diagnosed in 2016. This equates to 4,620 cases/day.
In 2016, about 595,690 Americans are expected to die of cancer, almost 1,630 people per day. Cancer is the second most common cause of death in the US, exceeded only by heart disease, accounting for nearly 1 of every 4 deaths.
The 5-year relative survival rate for all cancers diagnosed between 2003 and 2009 is 68%, up from 49% in 1975-1977
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide8“Lack of health insurance and other barriers prevent many Americans from receiving optimal health care. According to the US Census Bureau, approximately 48.6 million Americans (15.7%) were uninsured in 2011, including one in three Hispanics and one in 10 children (18 years of age and younger). Uninsured patients and those from ethnic minorities are substantially more likely to be diagnosed with cancer at a later stage, when treatment can be more extensive and more costly. The Affordable Care Act is expected to substantially reduce the number of people who are uninsured and improve the health care system for cancer patients.”
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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(1)
Slide9"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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(2)
Mecklenburg Co. 451.0
Cabarrus Co. 499.6
Union Co. 429.7
Stanly Co. 495.6
Gaston Co. 482.3
Slide10"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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(2)
Slide11(2)
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide12"
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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(2)
Slide13Biology of Cancer3
Senescence
Contact inhibition
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide14Where to begin?
Chart Review
Medical History
Current SymptomsCurrent Treatments Recent but Completed TreatmentsPotential POC
Overall what does the patient want?
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide15C = change in bowel or bladder habits
A = A sore that does not heal
U = unusual bleeding or discharge
T = thickening or lump in the breast or elsewhere
I = indigestion or difficulty in swallowingO = obvious change in a wart or mole
N = nagging cough or hoarseness
(4)
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide16Common Diagnostic Tests4
16
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide17Primary vs. metastatic4
Original tumor and location
Tumors that are a result of metastasis from the primary site
Can also come from external or genetic factors
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide18"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide19Common Metastatic Patterns
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide20Staging Cancer4,5
T: Primary Tumor
TX: primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ (site of origin)
T1,T2,T3,T4: Progressive increase in tumor size and local involvement
N: Regional lymph node involvement
NX: Nodes cannot be assessed
N0: No metastasis to local lymph nodes
N1, N2, N3: Progressive involvement of local lymph nodes
M: Distant metastasis
MX: Presence of distant metastasis cannot be assessed
M0: No distant metastasis
M1: Presence of distant metastasis
"
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide21Staging Examples5
T1, NO, MO
T2, N1, MO
“Clinical” vs. “pathological” Stage IV is always a Stage IV
T1,NO, MO rT2, rN1, rM1
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide22"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide23Grade of Cellular differentiation4,5
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide24"
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide25Treatments4,6
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide26Side Effects of Treatments 6,7
Emotional Effects
Anxiety/panic attacks
DepressionFear
Psychosocial Social Worker is available to follow both during and after hospital staySome psych medications have to be adjusted during cancer treatments
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide27Radiation7
Skin changes
Swelling
Fatigue
Hair loss in the treatment area
Mouth problems
Nausea & vomitingSexual changesUrinary & bladder changesRadiation FibrosisLymphedema
PainInfertilityPneumonitisPulmonary fibrosis
Radiation myelitis
Myelopathy
Joint problems
Secondary cancer
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Early
Late
Slide28Chemotherapy
7
Bone marrow suppression Appetite loss & weight changes
Taste changes
Mucositis Infection Fatigue Alopecia Memory/cognitive changes Nausea/vomiting Diarrhea/constipation
Peripheral neuropathy Pain
“Chemo Brain” or “chemo fog”
Cardiac toxicity
Central & cranial NS changes
Peripheral neuropathy
Pulmonary toxicity
Pulmonary fibrosis
Gastrointestinal toxicity
Liver Damage
Kidney and urinary damage
Sexual & fertility changes
Skin & nail changes
Tissue fibrosis
Alopecia
Psychosocial issues
Secondary cancer (rare)
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Early
Late
Slide29Chemo Drugs8,9,10
Alkylating
Agents
Busulfan,
Cisplatin, Carboplatin, Chlorambucil, Cyclophosphamide (cytoxan),
Ifosamide
,
Dacarbazine (DTIC), mechlorethamine, melphalan, temozolomideNitrosoureasCarmustine (BCNU), Lomustine (CCNU)Antimetabolites5-fluorouracil, capecitabine, 6-mercaptopurine, methotrexate, gemcitabine, cytarabine
(ara-C), fludarabine, pemetrexed
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide30Chemo Drugs cont’d8,9,10
Anthracyclines
and Related Drugs
Topoisomerase II InhibitorsMitotic InhibitorsCorticosteroid Hormones
Prednisone, dexamethasone"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide31Most common, debilitating complication
Oral mucosa very sensitive to chemo and radiation
Can impact nutrition
More complicated by nausea and vomiting
Shows up 5-10 days after treatment begins
Can last 1-6 weeks but depends on treatment
“Magic mouthwash”
Tonic contraction of muscles of masticationRestriction to opening mouth due to trauma, surgery or radiationCan lead to difficulty speaking, swallowing, and reduced nutritional intake
Compromised oral hygieneDepends on amount of radiation "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Mucositis
12,13
Trismus
12,13
Slide32Precautions and Considerations 7
Steroid Myopathy
Onset: insidious or rapid
Impairments: Proximal upper and lower extremity weakness
Rehab considerations/functional limitations:Difficulty ambulatingDifficulty climbing stairsDifficulty getting up from a chairDyspnea
Osteoporosis
Many cancer treatments may result in rapid and severe bone loss
Decreased bone mass increases risk of falls and fracturesRehab considerations:Spinal precautionsWeight bearing and resistive exercisesProper nutrition"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide33Medications
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide34Pain Medications8,9,10
Opiods
/Narcotics
Morphine, Dilaudid
Chart on next slideNonopiodsTylenol, AspirinNSAIDs Ibuprofen, Naproxen, Toradol, Advil, Nuprin
, Indocin
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide35Opiods
/Narcotics
A.K.A.
Parenteral
Oral
Morphine
X
X
Morphine Slow Release
MS Contin
NA
X
Hydromorphone
Dilaudid
X
X
Fentanyl
X
NA
Transdermal Fentanyl
NA
NA
Oxycodone
Percocet, Tylox
NA
X
Codeine
X
X
Hydrocodone
Vicodan, Lortab
NA
X
Meperidine
(Short Acting)
Demerol
X
X
Methadone
X
X
Levorphanol
Levo-Dromoran
X
X
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide36Anti-emetics 5
Zofran (
ondansetron
)Phenergan (promethazine) Ativan (
lorazepam)Marinol (dronabinol)
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide37Neuropathy13
Chemotherapy induced peripheral neuropathy (CIPN)
Neuropathic pain
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide38PNS13
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide39Presentation13
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide40Diagnostic Classification
Common Terminology Criteria for Adverse Events Version 4.03
13
Toxicity
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5Motor
Neuropathy
Asymptomatic,
clinical or
diagnostic
observations
only
Moderate
symptoms;
limiting
instrumental
ADL
Severe
symptoms;
limiting
selfcare
ADL;
assistive
device
indicated
Life-threatening
consequences;
urgent
intervention
indicated
Death
Sensory
Neuropathy
Asymptomatic,
Loss of DTR or
paresthesia
Moderate
symptoms;
limiting
instrumental
ADL
Severe
symptoms,
limiting
selfcare
ADL
Life-threatening
consequences;
urgent
intervention
indicated
Death
Paresthesias
Mild symptoms
Moderate
symptoms;
limiting
instrumental
ADL
Severe
symptoms,
limiting
selfcare
ADL
--
--
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide41Neurotoxic
Chemotherapeutics
13
Classes
Indications
Platinum
Analogues
Vinca
Alkaloids
Taxanes
Cisplatin
Vincristine
Paclitaxel
Carboplatin
Vinblastine
Abraxane
Oxalipatin
Vinorelbine
Docetaxel
Vindesine
Platinum
Analogues
Vinca
Alkaloids
Taxanes
Ovarian
Lymphoma
Ovarian
Lung
Leukemia
Breast
Testicular
Multiple Myeloma
Lung
Bladder
Breast
Bladder
Colon
Lung
Prostate
Colorectal
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide42Class
Recovery
Platinum
Compounds
-
Cisplatin
&
Carboplatin: Partial recovery, possible “coasting”-Oxaliplatin, acute: <1 week to resolve -Oxaliplatin, chronic: 3 months to resolve, rare long-term persistence↑ risk of sensory impairment as late effect (OR 1.62, 95% CI: 0.97-2.72)
Vinca Alkaloids
< 3 months to resolve
Vincristine
may continue
↑ risk of motor impairment as late effect (OR 1.66, 95% CI: 1.04-2.64)
Taxanes
<3 months to resolve May continue
(13)
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide43Functional Implications13
Deficits could be mild
Teach visual compensation
Skin protectionShoes, temperatures
Assess gait
Handwriting
ButtoningBalanceFallsStair negotiationDecreased UE function"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide44Lab Values
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide45CBC 8,9,10
"
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide46WBCs8,9,10
Produced in bone marrow
Indicates infection, inflammation
LeukocytosisLeukopenia
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide47ANC 8,9,10,14
Total number of neutrophils (mature white cells) circulating in the body
Calculated by multiplying WBCs x neutrophils
For instance, if the WBC count is 8,000 and 50% of the WBCs are neutrophils, the ANC is 4,000 (8,000 × 0.50 = 4,000).
Body’s ability to fight infectionNeutropenia – ANC is BELOW 1,000Severe neutropenia – ANC is below 500
–
severe risk of infection
Neutropenic FeverNeutropenic precautions – White Protective Environment Sign outside of room Neupogen (filgrastim)"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide48Hgb/HCT14
Hgb
HCT - % of RBCs in the blood
DecreasedAnemia, nutritional deficit, recent hemorrhage , fluid retention
Low BP, SOBIncreasedHemoconcentration, polycythemia vera, dehydrationBlood clots
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide49Platelets8,9,10
Thrombocytopenia
Avoid using BP cuffs
Use soft toothbrushesMonitor for changes that indicate intracranial bleeding (LOC, restlessness, H/A, seizures)
If available, encourage the ambulating patient to wear shoesMaintain bedrest during ACTIVE bleedingProtect from trauma
Thrombocytosis
Recent hemorrhage, infection, surgery
Glucocorticoids may increase counts"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."49
Slide50Fibrinogen 33
Fibrinogen 150-400 mg/
dL
Produced in the liver
Tests are run to check for:Bleeding disorders, thrombotic events, suspected DIC, abnormalities in coagulation panel (PT/PTT), liver disease, dysfibrinogenemia, and occasionally risk of CADIncreased levels can be seen in:
Inflammation, tissue damage/trauma, infection, cancer, acute coronary syndrome, strokes
Decreased levels can be seen in:
Afibrinogenemia, hypofibrinogenemia, end stage liver disease, severe malnutrition, disseminated intravascular coagulation (DIC), abnormal fibrinolysis, and large volume blood transfusions"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."50
Slide51Fresh Frozen Plasma (FFP) 34
To treat the prolonged
protime
(PT) and activated partial thromboplastin time (aPTT) associated with hypofibrinogenemia
Not optimal blood component due to the large volumes of plasma required to increase fibrinogen to hemostatic levels
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide52FFP 56
The plasma taken from a whole unit of blood
Contains all coagulation factors in normal concentrations
May be transfused up to 5 days after thawing
Plasma is free of RBCs, WBCs, and plateletsIndicated in patients with documented coagulation factor deficiencies and active bleeding, or who are about to undergo an invasive procedure.Deficiencies may be congenital or acquired secondary to liver disease, warfarin anticoagulation, disseminated intravascular coagulation, or massive replacement with red blood cells and crystalloid/colloid solutions.
Usually, there is an increase of at least 1.5 times the normal PT or PTT, or an INR ≥ 1.6 before clinically important factor deficiency exists. This corresponds to factor levels <30% of normal.
Conditions that may affect platelet function include renal failure, medications,
leukemias and myelodysplasias, and congenital disorders.""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide53FFP 56
Plasma - Dosage
Volume of 1 Unit Plasma: 200-250 mL
1 mL plasma contains 1 u coagulation factors
1 Unit contains 220 u coagulation factorsFactor recovery with transfusion = 40%1 Unit provides ~80 u coagulation factors
70 kg X .05 = plasma volume of 35
dL
(3.5 L)80 u = 2.3 u/dL = 2.3% (of normal 100 u/dL) 35 dLIn a 70 kg Patient:1 Unit Plasma increases most factors ~2.5%4 Units Plasma increase most factors ~10%Initial Dose of FFP10cc/Kg (round up to nearest 200cc) = #units FFP / 200 cc/unit FFPTherapeutic EffectUsually an increase in factor levels of at least 10% will be needed for any significant change in coagulation status, so the usual dose is four units, but the amount will vary depending on the patient's size and clotting factor levels. Hematology consultation is advised concerning the dose of plasma.
"
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide54FFP 56
""
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Recommended Coagulation Parameters
for Common Procedures
Platelet Count*
INR
Lumbar Puncture
≥50,000
≤1.5
Paracentesis
≥30,000
≤2.0
Thoracentesis
≥50,000
≤1.5
Transbronchial Lung Biopsy
≥50,000
≤1.5
Subclav/IJ Line
≥30,000
≤1.5
Renal Biopsy
≥50,000
≤1.5
Liver Biopsy
≥50,000
≤1.5
Hickmann
,
Groshong
Catheters
≥50,000
≤1.5
Slide55Cryoprecipitate 34,55
Proteins that precipitate out of solution when a unit of fresh frozen plasma is slowly thawed out in the cold
Prepared from one unit of FFP
Outdates 6 hours after being thawed or 4 hours after being pooled
ABO compatible cryoprecipitate is desirable if large volumes will be transfusedCan be transfused quicklyPreferred because it contains same concentration of fibrinogen as FFP in less than 1/20 of the volume
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide56Electrolytes8,9,10,14
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide57BUN (Blood Urea Nitrogen)/Creatinine
BUN normal range - 6 to 20 mg/
dL
.
Creatinine – normal range - 0.7 to 1.3 mg/dL for men and 0.6 to 1.1 mg/dL for women.
Often evaluated together with the ratio being 15:1-24:1
BUN – the most prevalent of non-protein nitrogenous compounds in blood. Increased in instances of renal failure and gastro-intestinal bleeding
Most chemo excreted through kidneys which is why good function is importantBUN – down in severe liver damage, up in kidney diseaseCr – up in kidney damage, down in severe liver disease
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."57
Slide58Na
The normal range for blood sodium levels is 135 to 145
mEq
/L.regulation of body waterHypernatremia s/s thirst, restlessness, HTN, SOB
Hyponatremia lethargy, confusion, focal weakness, seizureSIADH – oncologic emergency
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide59K+
The normal range is 3.7 to 5.2
mEq
/L.regulation of muscle activity (essential in maintaining electrical conduction of heart and skeletal muscles)
HypokalemiaDiaphoresis, Decreased reflexes, Confusion, Hypotension, Anorexia, EKG changesHyperkalemia ARF, Leukemia, Weakness, Malaise, Nausea, Diarrhea, Decreased HR
Tumor
Lysis
syndrome – oncologic emergency""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."59
Slide60Cl
A typical normal range is 96 to 106
mEq
/L.regulation of blood volume and arterial pressureHypochloremia
Addison disease, Bartter syndrome, Burns, CHF, dehydration, Excessive swelling, hyperaldosteronism, metabolic alkalosis, Respiratory acidosis (compensated) SIADH, VomitingHyperchloremia.Carbonic anhydrase inhibitors (used to treat glaucoma), Diarrhea, Metabolic acidosis, Respiratory alkalosis (compensated), Renal tubular acidosis
"
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
60
Slide61CO2
The normal range is 23 to 29
mEq
/L
good indictator of acidosis and alkalinitymost of the CO2 is in the form of a substance called bicarbonate (HCO3-). Therefore, the CO2 blood test is really a measure of your blood bicarbonate level.Higher-than-normal levels
Breathing disorders, Cushing syndrome,
Hyperaldosteronism
, VomitingLower-than-normal levelsAddison disease, Diarrhea, Ethylene glycol poisoning, Ketoacidosis, Kidney disease, Lactic acidosis, Metabolic acidosis, Methanol poisoning, Salicylate toxicity (such as aspirin overdose)"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."61
Slide62Calcium/Phosphorus
Normal values range from 8.5 to 10.2 mg/
dL
.
Neuromuscular, skeletal and endocrine disordersHypocalcemia Renal failure, Acute pancreatitis
Hypercalcemia
–
Metastatic CA, Multiple fractures, Prolonged immobilizationSigns and symptoms: nausea, vomiting, dehydration, confusion (elderly), lethargy, muscle weakness, coma Tumor lysis syndromeNormal values range from 2.4 to 4.1 mg/dL.Phosphorus – generally inverse with calcium
Build strong bones and teethAlso important for nerve signaling and muscle contractionKidney, liver, and certain bone diseases can cause abnormal phosphorus levels
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide63Other Lab Values 14
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
63
Slide64TYPES OF CANCER 8,9,10
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide65Different types of Cancer8,9,10
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
65
Slide66Lung Cancer 8,9,10
Small Cell Lung CA – most rapid, responds well to chemo
Non-Small Cell Lung CA – does not respond well to chemo, radiation curative for stage I or II or as an adjunct to
sx
Smoking is directly related to this CA
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
66
Slide67Lung Cancer 50
Symptoms
Cough that doesn’t go away and gets worse over time
Constant chest pain
Coughing up bloodSOB, wheezing, or hoarsenessRepeated problems with pneumonia or bronchitisSwelling of the neck and faceLoss of appetite or weight loss
Fatigue
Risk Factors
SmokingSecondhand smokeRadonPersonal or family history of lung cancerRadiation to the chestDiet"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide68Lung Cancer 50, 51
Diagnosing
Chest CT
Needle Biopsy with Endoscopic UltrasoundChest X-ray
BronchoscopyMRIPET Radionuclide bone scanPulmonary function test (PFT)
Staging of NSCLC
Occult
Stage 0Stage I – in lungStage II – in lymph nodesStage IIIA – beginning spread out of lungStage IIIB – above collarbone and to opposite side of chest Stage IV – both lungs, in fluid around the heart, and to the rest of the body
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide69Lung Cancer 52
Staging of SCLC
Limited-Stage
In the lung where it started and may have spread to the area between the lungs or to the lymph nodes above the collarbone
Extensive-Stage Cancer has spread beyond the lung or the area between the lungs or the lymph nodes above the collarbone to other places in the body Treatments SCLCSurgery Chemotherapy Radiation therapy Laser therapy
Endoscopic stent placement
Treatments NSCLC
Surgery Radiation therapy ChemotherapyTargeted therapy Laser therapy Photodynamic therapy (PDT)Cryosurgery Electrocautery"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
69
Slide70Colorectal Cancer 8,9,10,45
Symptoms
Diarrhea, constipation or consistency lasting >4
wks
Rectal bleedingPersistent gas, pain, or crampsDon’t feel like emptied completelyWeakness/fatigueUnexplained weight loss
Risk Factors
Older age >50
yrsAfrican American raceFamily historyH/o Crohn’s or ulcerative colitisGenetic syndromesLow fiber, high fat dietSedentary lifestyleDiabetesObesitySmoking/Alcohol
Radiation therapy from previous cancers"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide71Colorectal Cancer 45
Diagnosing
Should begin at age 50 with colonoscopy
Biopsies can be taken if needed
Blood testsStaging Stage I – grown through mucosa of colon or rectum but not beyond
Stage II
–
grown into wall or through wall of color or rectum but NO lymph nodesStage III – invaded nearby lymph nodes but no other parts of the bodyStage IV – spread to distant sites like liver or lung"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide72Colorectal Cancer Treatment 45
Surgery is primary treatment for 75% of cancers, radiation can be pre or postop
Early Stage
Remove polyps during colonoscopyEndoscopic mucosal resection
Minimally invasive surgery laparoscopicallyInvasivePartial colectomy Placement of a colostomy bag (temporary or permanent)Careful when mobilizing these patients!
Lymph node removal
Chemo/Radiation/Targeted drug therapies
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."72
Slide73Malignant Pleural Effusions and PleurX Catheters 39
Used to treat malignant ascites
Ascites
–
collection of fluid in the peritoneal cavity – in 50% of cancer patientsFluid obstructs lymph system and blocks flow to circulatory systemPatients often require multiple paracenteses
Increased ascites = abdominal pain, dyspnea, nausea, vomiting, and anorexia
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide74Cervical Cancer 35
One of the most preventable types of cancer
Continues to decline in prevalence every year due to use of Pap smears to detect abnormalities and patients to get earlier treatment
Most women diagnosed between 35-55, rarely those under 20
90% are squamous cell cancers, adenocarcinomas account for the remaining 10-20%HPV is found in 99% of cervical cancers
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide75Cervical Cancer cont’d 35
Signs and Symptoms
Abnormal or Irregular Bleeding
Bleeding AFTER menopause
Pelvic pain not related to menstrual cycleHeavy or unusual discharge that may be watery, thick, and possibly have a foul odorIncreased urinary frequency
Pain during urination
Pain during sex
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."75
Slide76Cervical Cancer Stages 35
Stage 0
: Carcinoma in situ. Abnormal cells in the innermost lining of the cervix.
Stage I
: Invasive carcinoma that is strictly confined to the cervix.Stage II: Locoregional
spread of the cancer beyond the uterus but not to the pelvic sidewall or the lower third of the vagina.
Stage III
: Cancerous spread to the pelvic sidewall or the lower third of the vagina, and/or hydronephrosis or a nonfunctioning kidney that is incident to invasion of the ureter.Stage IV: Cancerous spread beyond the true pelvis or into the mucosa of the bladder or rectum."Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
"76
Slide77Cervical Cancer Treatments 35
Total hysterectomy - Surgery to remove the uterus, including the cervix.
Hysterectomy - The uterus is surgically removed with or without other organs or tissues.
Radical Hysterectomy - Surgery to remove the uterus, cervix, part of the vagina, and a wide area of ligaments and tissues around these organs. The ovaries, fallopian tubes, or nearby lymph nodes may also be removed.
Modified Radical Hysterectomy - Surgery to remove the uterus, cervix, upper part of the vagina, and ligaments and tissues that closely surround these organs. Nearby lymph nodes may also be removed. In this type of surgery, not as many tissues and/or organs are removed as in a radical hysterectomy.
Pelvic
Exenteration
- Surgery to remove the lower colon, rectum, and bladder. In women, the cervix, vagina, ovaries, and nearby lymph nodes are also removed. Artificial openings (stoma) are made for urine and stool to flow from the body to a collection bag. Plastic surgery may be needed to make an artificial vagina after this operation.Cryosurgery - A treatment that uses an instrument to freeze and destroy abnormal tissue, such as carcinoma in situ. Laser surgery - A surgical procedure that uses a laser beam (a narrow beam of intense light) as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.Loop electrosurgical excision procedure (LEEP) - A treatment that uses electrical current passed through a thin wire loop as a knife to remove abnormal tissue or cancer.RadiationChemotherapy
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide78Endometrial Cancer 42
95% of cases
Most common type of uterine cancer
Develops in the lining of the uterus (endometrium)Uterine sarcoma is more rare
Symptoms:Abnormal, non-bloody vaginal dischargePelvic pain or crampingUnexplained weight lossA tumor or massDifferential Diagnosis – GI bleed
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide79Ovarian Cancer 8,9,10,44
Back pain
Bloating/swelling/discomfort in pelvis area
Feeling of fullnessUrinary urgency or incontinence
ConstipationWeight loss“silent killer”Usually history of breast, endometrial or colon CA in familySx, TAH, chemo –
intraperitoneal
chemo
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide80Ovarian Cancer 44
Types
Epithelial tumors
90% of ovarian cancersStromal tumors
7% of ovarian cancersGerm cell tumors Rare and occur in younger women Risk Factors
Most common in women ages 50-60
Inherited gene mutation BRCA1 and BRCA2
Estrogen hormone replacement therapyEarly menstruation or late menopauseNever being pregnantFertility treatmentSmokingIUDPolycystic ovary syndrome"Managing the Cancer Patient in the Acute Care Setting," 6/14/14, "This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide81Ovarian Cancer 44
Staging
Stage I
– in one or both ovariesStage II
– spread to other parts of pelvisStage III – spread to the abdomenStage IV – outside the abdomen
Treatment
Usually a combination of surgery and chemotherapy
"Managing the Cancer Patient in the Acute Care Setting," 6/14/14, "This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."81
Slide82Breast Cancer 8,9,10
Breast – personal or family history
Early menarche, late menopause – increase in estrogen
Late first pregnancy, no pregnancy – increase in estrogen
Exogenous estrogen – after removal of ovariesSentinel node biopsy – 1st node blue dye drains to for breast CA and melanoma
"Managing the Cancer Patient in the Acute Care Setting," 6/14/14, "This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
82
Slide83Prostate Cancer 49
Most common cancer among men in the U.S. with 1 in 7 men getting diagnosed
Often has no early symptoms
Most do not die from it with more than 2.9 million men still alive today after diagnosis
Detected by Prostate specific antigen (PSA) in bloodstream – if levels are high, either prostate cancer or some kind of conditionMany men have died and then been found during autopsy to have had prostate cancer – roughly 80% of men in their 80s
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
83
Slide84Prostate Cancer 49
Symptoms
Frequent urination
Nocturia
Hard to start urinatingHard to keep urinating once startedHematuriaPainful urinationEjaculation may be painful
Difficulty achieving or maintaining erection
Bone pain (pelvis, spine, ribs, femur)
Leg weaknessUrinary and fecal incontinenceCausesMuch more common after 50Genetics – BRCA2Diet – low vitamin DMedicationObesitySTDs - gonorrhea
Agent Orange – 48% higher risk Enzyme PRSS3 – changes environment of prostate cancer cells – more likely to metastasize
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
84
Slide85Prostate Cancer 49
Staging
Clinical T1 and T2
– only in prostate
Clinical T3 and T4 are outside the prostateGleason Score Grades tumor after biopsy sample examined microscopicallyTwo numbersNumber 1-5 for most common pattern observed more than 51% of sampleNumber 1-5 for second most common pattern more than 5% but less than 50%
Example
Predominant grade is 3 and secondary grade is 4, Gleason score is 7
Predominant grade is 4 and secondary grade is 3, Gleason score is 7First example has a less aggressive cancer than the second example with a lower predominant score"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."85
Slide86Prostate Cancer 49
Possible complications
Metastasis
– through blood or lymph to other organs or bonesIncontinence
Erectile dysfunctionMetabolic factors – much higher risk of death with HTN, DM, high BMI and high blood lipid levelsTreatmentsRadical prostatectomyBrachytherapy
–
radioactive seeds are implanted
Conformal radiotherapy – conformed to area to minimize healthy tissue exposure Intensity modulated radiotherapy - beams with variable intensity"Managing the Cancer Patient in the Acute Care Setting," 6/14/14, "This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."86
Slide87Liver Cancer 47
Symptoms
Unexplained weight loss
Loss of appetiteUpper abdominal pain
N/VGeneral weakness and fatigueAbdominal swellingJaundiceWhite, chalky stools
Risk Factors
Chronic infection with HBV or HCV (
Hep B or Hep C)CirrhosisInherited liver diseasesDiabetesNonalcoholic fatty liver diseaseExposure to aflatoxins (molds on crops that are stored poorly)Excessive alcohol consumption
""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide88Liver Cancer 47
Surgery
To remove the tumor
Liver transplant surgery
Treatments Radiofrequency ablation – electric current is used to heat and destroy cancer cells
Cryoablation
- Freezing cancer cells
Injecting pure alcohol into tumorChemoembolization – supplies strong anti-cancer drugs directly to liverPlacing beads filled with radiation in the liver "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide89Kidney Cancer 48
Case Study Example
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
89
Slide90Kidney Cancer 48
Signs/Symptoms
Hematuria
Constant side/flank painLump/mass in abdomen or side
Intermittent FeverWeight lossFatigueAnemia
Risk Factors
Smoking
ObesityHTNLong-term dialysisMale genderVon Hippel-Lindau (VHL) SyndromeOccupational exposure (asbestos)"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide91Kidney Cancer 48
Types
Clear Cell
Papillary renal cellChromophobe
renal cellStagesMeasuring size of tumorLocation of the cancer cells either confined to the kidney, locally spread, or widespread beyond the fibrous tissue surrounding the kidney (stages I-IV)
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide92Kidney Cancer 48
Treatments
Chemotherapy
Radiation TherapyEmbolization
Biological TherapySurgery"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide93Pancreatic Cancer
Signs/Symptoms
Upper abdominal pain that radiates to your back
JaundiceLoss of appetiteWeight loss
DepressionBlood clots Risk Factors African American RaceObesity
Pancreatitis
Diabetes
Genetic syndromesPersonal/family h/o pancreatic cancerSmoking"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."93
Slide94Diagnosing Pancreatic Cancer
US
CT
MRIEndoscopic Ultrasound (EUS) – makes images of pancreas and can collect cell samples
Endoscopic Retrograde Cholangiopancreatography (ERCP) – uses a dye to highlight the bile ducts in your pancreas
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide95Pancreatic Cancer
Staging
Stage I- confined to pancreas
Stage II –
beyond pancreas to nearby tissues/organs and possibly lymph nodesStage III – beyond pancreas to major blood vessels around pancreas, maybe to lymph nodesStage IV – spread to distant sites beyond the pancreas, such as the liver, lung, and peritoneum
Surgery
Whipple (
pancreatoduodenectomy) – sx for tumors in the pancreatic headDistal Pancreatectomy – sx for tumors in the pancreatic tail and body, might also remove spleen
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide96Leukemia8,9,10
""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
96
Slide97Invasive Fungal Infections (IFI) in AML 37
Among the leading causes for morbidity, mortality (35%), and economic burden (
LOS, healthcare expenditures)
Incidence has increased dramatically by 200% from 1979-2000Management complicated by increasing frequency of infection by non-Asperigillus molds (zygomycosis) and emergence of drug-resistant fungal pathogens
Aspergillus
and
Candidemia account for majority of casesInfection of blood stream, lungs, and sinuses is most common"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide98IFI in AML cont’d 37
Risk factors:
colonization of yeast in the GI mucosa with acute mucosal damage caused by cytotoxic drugs (e.g. high-dose
cytarabine)
NeutropeniaUse of broad-spectrum antibacterial therapyBacteremiaRenal insufficiencyProlonged stay in an ICUReceipt of TPNRecent GI surgical procedure
"
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide99IFI in AML cont’d 37
Management:
Early initiation of antifungal therapy with various medications based on the fungus being treated
Prognosis:
Achievement of remission of AL can also lead to the recovery of neutropenia and positively affect the outcome of fungal infectionInvasive candidiasisInvasive aspergillosisZygomycosis
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide100Multiple Myeloma 4
Malignancy of plasma cells
Slow progression
Pathological compression fractures especially in vertebral bodiesOften how they present to the hospital where no trauma occurred but a fracture has been found
Dehydration is commonNo treatment is curative
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide101Multiple Myeloma Patient Examples
Mrs. Purple
Mr. Yellow
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide102Lymphoma 57
Lymph system affected includes: lymph, lymph vessels and nodes, spleen, thymus, tonsils and bone marrow
Lymph tissue is also found in brain, stomach, thyroid gland and skin
Hodgkin and Non-Hodgkin
""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E.
Tasillo
, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide103Hodgkin’s and Non-Hodgkin’s Lymphoma4
Nodal involvement
Extranodal
involvement
Hodgkin’s and Non-Hodgkin’s Lymphoma
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
103
Ann Arbor Classification
A = means without symptomsB = with symptoms like night sweats, unexplained weight loss and feversEx: Stage IIIS A
Slide104Follicular Lymphoma 38
A B-cell lymphoma
Most common, slow-growing form
–
20-30% of all NHLsCommon signs/symptoms:Enlarged lymph nodes in neck, underarm, stomach, groinFatigueSOBNight sweatsWeight loss
Usually no symptoms of disease at time of diagnosis
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide105Follicular Lymphoma 38
Treatment:
Very responsive to radiation and chemotherapy
If no symptoms, often not treated right awayMany achieve remission but disease often returns later
Common chemotherapy combos:R-Bendamustine (rituximab and bendamustine)R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone)
R-CVP (rituximab, cyclophosphamide, vincristine, prednisone)
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide106Follicular Lymphoma Case Study – Mr. Red
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide107AIDS-Related Lymphoma 57
Malignant cells form in the lymph system of patients who already have AIDS
However, sometimes this can be the first diagnosis for both AIDS and the AIDS-related lymphoma
Sometimes this type of cancer can occur outside lymph nodes in bone marrow, liver, meninges, and GI tract
Non-Hodgkin Lymphoma more common and called AIDS-related lymphomaWhen occurs in the CNS: AIDS-related primary CNS lymphoma
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E.
Tasillo
, PT, DPT, and should not be copied or otherwise used without express written permission of the author."107
Slide108AIDS-related NHL 57
These lymphomas are the aggressive type
Diffuse Large B-cell lymphoma (including B-cell
immunoblastic
lymphoma)Burkitt or Burkitt-like lymphoma Signs and symptoms:Weight lossFever
Night sweats
Painless, swollen lymph nodes in the chest, neck, underarm or groin
A feeling of fullness below the ribs "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."108
Slide109Stages of AIDS-related Lymphoma 57
E: "E" stands for
extranodal
and means the cancer is found in an area or organ other than the lymph nodes or has spread to tissues beyond, but near, the major lymphatic areas.
S: "S" stands for spleen and means the cancer is found in the spleen.
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E.
Tasillo
, PT, DPT, and should not be copied or otherwise used without express written permission of the author."109
Slide110Stage I – one lymphatic areaStage IE – one organ or area outside of the lymph nodes
Stage II – two or more lymph nodes either above/below the diaphragm
Stage IIE – Also found outside the lymph nodes in one organ or area on the same side of the diaphragm as the affected lymph nodes
Stage III – one or more lymph node groups above AND below diaphragm
Stage IIIE – AND outside the lymph nodes in a nearby organ or areaStage IIIS – AND in the spleenStage IIIE plus S - the three stages above combined
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E.
Tasillo
, PT, DPT, and should not be copied or otherwise used without express written permission of the author."110
57
Slide111Stage IV is found throughout one or more organs that are not part of a lymphatic area (lymph node group, tonsils and nearby tissue, thymus, or spleen) and may be in lymph nodes near those organs; or
is found in one organ that is not part of a lymphatic area and has spread to organs or lymph nodes far away from that organ; or
is found in the liver, bone marrow, cerebrospinal fluid (CSF), or lungs (other than cancer that has spread to the lungs from nearby areas).
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E.
Tasillo
, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
111
57
Slide112Treatment 57
For treatment, AIDS-related lymphomas are grouped based on where they started in the body
Peripheral/systemic lymphoma
Primary CNS lymphoma
cART (combined antiretroviral therapy)Clinical trials
Chemotherapy
Intrathecal
Ommaya reservoir Regional CombinationRadiationExternalInternalStem cell transplant Targeted therapy Monoclonal antibody therapy
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
112
Slide113"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E.
Tasillo
, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
113
Slide114Special Patient Populations
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
114
Slide115Neck Dissections 3,4,7
Tobacco use is closely associated with this cancer type
Underlying lung disease could be present if tobacco was involved prior
New prevalence of head and neck cancer associated with the HPV virus
Three flaps: pectoralis, fibular, radial forearmFocusing on posture and positioning, cervical, shoulder, and scapular ROM and movement during recovery is vitalMultiple lines and tubes can make this patient population appear difficult from the beginning
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author.”
115
Slide116BMT4,15
Types – Allogeneic vs. Autologous
Body is immunosuppressed prior to transplant – period called
cytoreduction
(usually 2-4 days) of chemo, radiation, or bothAspiration from posterior/anterior iliac crest1-3 days after last dose of chemo/radiation – transplant is administered either through central venous access device or a Hickman right atrial catheterBMT vs. PBSCT
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
116
Slide117“Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E.
Tasillo
, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
117
Slide118Can be used to treat patients with: 4,15
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
118
Slide119Afterward4…
Bone marrow failure begins within 10 days after transplant and can last up to 3 weeks
Neutrophil count less than 1,000/mm
3
= reverse protective isolationPlatelets less than 50,000/mm3 = thrombocytopenic precautions Stem cells begin functioning 10-28 days after transplantA successful engraftment = increase in platelet and WBC count (again 10-28 days afterward)
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
119
Slide120Complications4
Infection
Pneumonia
HemorrhageMarrow failureVeno
-occlusive disease of the liverInterstitial pneumonitisGraft versus host disease
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
120
Slide121GVHD 36
The older the person, the higher the risk
Donor’s immune cells attack patient’s good cells
Can be mild, moderate or severe
Symptoms can be:Rashes – palms and soles, then to trunk, then to entire bodyBlistering – exposed skin flaking off in severe casesNausea/vomiting/abdominal cramps, diarrhea, loss of appetite
Jaundice
Excessive dryness of mouth and throat, leading to ulcers
Dryness of the lungs, vagina and other surfaces"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide122GVHD 36
Acute vs. Chronic
Acute
– soon after transplant cells begin to appear in recipient
Chronic – usually at 3 months post transplant but can be a year or more laterUsually starts with a rash/itchingSkin, GI tract and liver are mainly targeted
Less commonly
–
involvement of the hematopoietic system, eyes, and kidneysMany deaths occur due to infection with patients with suppressed immune systems"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."122
Slide123GVHD 40
"Managing the Cancer Patient in the Acute Care Setting," 6/14/14, "This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
123
STAGE
SKIN
GI TRACT
LIVER
1
Maculopapular rash over <25% of body areaDiarrhea
500-1000 mL/day
Bilirubin
2-3 mg/
dL
2
Maculopapular
rash 25-50% of body area
Diarrhea
1000-1500 mL/day
Bilirubin 3-6 mg/
dL
3
Generalized
erythroderma
Diarrhea
1500-2000 mL/day
Bilirubin 6-15 mg/
dL
4
Generalized
erythroderma
with bullous formation, often with desquamation
Diarrhea
>2000 mL/day or pain or ileus
Bilirubin >15 mg/
dL
Slide124Prevention Drugs for GVHD 36
Prevention
Cyclosporine and methotrexate
Tacrolimus (Prograf
) and methotrexateTacrolimus and mycophenolate mofetil (CellCept)
Prograf
and
sirolimus (Rapamune)TreatmentGlucocorticoids (prednisone or methylprednisone) combined with cyclosporine – acute GVHDCorticosteroids – chronic GVHD"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
124
Slide125Extracorporeal Photophoresis 41
Cell-based
immunomodulatory
therapy that involves collecting leukocytes from peripheral blood
Exposed to a photosensitizing agent, then treated with UV radiation, and then reinfusedProduces mass apoptosis of the treated cellsReduced risk of infections with ECP as compared to other immunosuppressive agentsUsually done as a steroid-sparing maneuver or as a last ditch effort
Many complications are related to vascular access
Infection, clotting in catheters, DVTs, and vessel stenosis
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide126GVHD Case Study
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
126
Slide127Donor Lymphocyte Infusions (DLI) 53, 54
Uses the immune system to fight the tumor
T cells, a leukocyte, can cause GVHD as well as initiate an attack on the malignant cells that remain after high doses of chemotherapy and radiation
Used for patients when they present with relapse after an allogenic bone marrow transplant
Receives a boost of immune cells from the donor's original blood Especially helpful in those with CML but can be used in other leukemias
or lymphoproliferative disorders
Can cause GVHD or marrow toxicity however (mild or moderate)
Toxicity can be less severe than a second transplant Also experience a marked drop in blood counts as bone marrow switches back to donor cells In some cases, patients can receive multiple infusions until remission is achieved or side effects are lessened Those at high risk for relapse after BMT are sometimes offered this treatment while still in remission "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
127
Slide128BMT Program at CMC
Handouts
Gym
PeddlerShower chairStaff Education
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
128
Slide129Current Barriers in our new BMT program
Arrival of patients and timeliness of baseline assessment for both PT and OT
Often times, patients do not fully understand the necessity of this evaluation when they are “fine”
Some have already begun chemotherapy by the time a therapist gets to the patient, they are not 100% since they are already feeling the side effects
Still developing what the evaluation will look like for both disciplines as they can be quite lengthy – what can be held off until follow up session?
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
129
Slide130What is to come in our BMT unit…
Hardwire the assessment and follow up assessment time frames
Hardwire mobility piece when therapy is not directly involved
Development of a stretching and balance program on the BMT unitImplement an incentive program in conjunction with the activity logs that patients are given upon arrival to encourage frequent mobility
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
130
Slide131Mastectomy 16
Initial Mastectomy procedure
DIEP flap
This population is now solely under the OT umbrella unless a major mobility deficit requires PT involvement
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
131
Slide132Sarcoma
17,18
Most common type of cancer that STARTS in the bone
Limb sparing surgery
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
132
Slide133Red Flags 7
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
133
Slide134Oncologic Emergencies7,8,9,10
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
134
Slide135SIADH
Syndrome of inappropriate antidiuretic hormone
“water intoxication”
All cancers have the ability to cause SIADH, however, cancers with known ectopic hormone production have a higher incidence of SIADHSmall cell lung cancer is most common
S/s confusion, weakness, muscle cramps, edema, lethargy, N/V, irritabilityManaged by fluid restriction and lasix
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
135
Slide136Tumor Lysis Syndrome
Destruction of large number of cells releasing potassium, phosphorus, and uric acid in blood with concurrent binding of calcium ions
HYPOCALCEMIA
Seen a lot with leukemic patientsSigns and Symptoms: Hyperuricemia
(>8), hyperkalemia (>5.5),
hyperphosphatemia
(>5.5), hypocalcemia (>4.0), arrhythmia, bradycardia, uric acid crystals, elevated serum creatinine, seizures, weakness, confusion, irritability, numbness and tingling, muscle cramping, weight gain, edema, decreased urine output*Side note* - Uric acid crystals can cause kidney failure because uric acid crystals create blockages in the kidneysMedical management includes intravenous hydration, correction of metabolic alterations, and treatment of renal failure. Aggressive hydration is recommended for all patients, as this reduces the risk for calculi formation and obstructive nephropathy. Oral or intravenous allopurinol (110 mg/m2 every 8 hours) is recommended for treatment of hyperuricemia
in low- or intermediate-risk patients.Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
136
Slide137Superior Vena Cava Syndrome
obstructed venous flow through the SVC resulting in impaired venous drainage from the head and upper extremities
Occurs 75% in lung CA, 15% in lymphoma
Edema of head and UEs
Signs and symptoms: headache, cough, visual disturbances, dizziness, chest pain, tachypnea, cyanosisMedical Management: chemo, radiation, diuresis, oxygen, tranquilizers, steroids, anticoagulants
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
137
Slide138DIC (Disseminated Intravascular Coagulation)
MAJOR EMERGENCY
Common in leukemic patients
Abnormal activation of both coagulation and fibrinolysis factors leading to uncontrolled bleeding and thrombosis
thrombi lodge in microcirculation block capillary flow severe tissue ischemia
bleeding can occur anywhere and once it starts it cannot be reversed
Signs you might see: intracerebral bleeding, petechiae, hematuria, oozing of mucous membranes or profound menstrual or GI bleedingCan help some with more blood productsManaging the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
138
Slide139Spinal Cord Compression
Very common
Predominantly caused by metastatic spread of a primary malignancy through direct extension,
hematogenous spread that causes mechanical compression, impaired vascularization, or vertebral compression with nerve entrapment
Most common in metastatic breast, lung, prostate, kidney, lymphomaManaged by radiation, steroids, surgery, analgesicsCheck to see if MRI was done; if not, call MD regardless of activity orders
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
139
Slide140Sepsis Severe Sepsis Septic Shock 43
Sepsis: must have at least two of the following:
Temp above 101 F or below 96.8 F
HR higher than 90 bpm
RR higher than 20 breaths/min
Severe Sepsis:
Significantly decreased urine outputAbrupt change in mental statusDecrease in platelet countDifficulty breathingAbnormal heart pumping functionAbdominal pain Septic Shock you have the s/s of severe sepsis with the extremely low blood pressure that doesn’t adequately respond to simple fluid replacement
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
140
Slide141Sepsis Cont’d 43
Causes
Pneumonia
Abdominal infectionKidney infection
BacteremiaRisk Factors Very young or very oldCompromised immune systemAlready sick, often in an ICU
Wounds/injuries such as burns
Have intravenous catheters or breathing tubes
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."141
Slide142Sepsis Cont’d 43
Complications
Blood flow to vital organs (brain, heart, kidneys) becomes impaired
Blood clots can form in organs and arms, legs, fingers, toes
organ failure and gangreneMortality rate of septic shock is 50%Treatment
Antiobiotics
Vasopressors
OxygenLarge amounts of IV fluidsIn some cases, dialysis or ventilatorSurgery to remove abscesses in other casesManaging the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."142
Slide143Diabetes and the Cancer Patient8,9,10,19
Chemotherapy
Renal function already impaired from diabetes and is only worsened with chemo
GlucocorticoidsIncrease BS and insulin will be given – increased weightTube feeding and TPN
BS monitored every 6
hrs
Nausea and vomitingStress hormones will raise BS even with no food on board after N&V"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."143
Slide144Goals of Therapy – Dietz20,21
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
144
Slide145Karnofsky Criteria of Performance Status21
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
145
Slide146Eastern Co-operative Oncology Group (ECOG)22
0 Fully active, able to carry on all
predisease
performance without restriction
1 Restricted in physically strenuous activity, but ambulatory and able to carry out work of a light and sedentary nature (e.g. light house work, office work)2 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours3 Capable of only limited self-care, confined to bed or chair more than 50% of waking hours
4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair.
5 Dead
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."146
Slide147Battling Cancer Related Fatigue4,7
Bedrest
will only make it worse!
Defined by the National Comprehensive Cancer Network as a “persistent, subjective since of tiredness related to cancer or cancer treatment that interferes with usual functioning.”
According to Vogelzang et al. patients indicated that fatigue affected their daily lives more than pain
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
147
Slide148So how do we fight fatigue?7
Fatigue scale
Exercise to address decreased biologic resources
Incorporate rest breaks
Plan treatment session when patient has the most energy to maximize treatment qualityEnergy conservation techniques/ergonomicsSleep and wake schedule
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
148
Slide149(23)
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
149
Slide150"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
150
(23)
Slide151Pain
7
Overall, pain is reported by ~50% of people at
all stages of disease and over 70% with
advanced neoplasms
Types of pain: somatic, visceral, neuropathic
Pre-medicate if necessary
Red flags "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."151
Slide152Emphasis on Exercise4,7
Goals:
Optimize functional mobility
Minimize cancer-related fatigue
Prevent joint contracture/skin breakdownPrevent/reduce limb edemaPrevent post-op pulmonary complications
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
152
Slide153How hard do I push them though?4
Exercise intensity should be between 1 and 4
Aerobic
Progressive, building duration over time
An exercise log is important for monitoring progress as well as adherence
"
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
153
Slide154General
Oncological
Surgical Considerations
7
Precautions/restrictions: WB, ROM, surgery specificReconstruction: skin grafts, nerve grafts, tendon transfers, flap coverage
Bone graft donor sites
Real & phantom pain
Leg length discrepancyCosmetic deformityLymphedemaEdema: post-surgical vs venous insufficiencyPulmonary statusEarly mobility
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
154
Slide155Surgical Interventions(24,25)
Total Pelvic
Exenteration
Abdominoperineal ResectionRadical ProstatectomyRadical CystectomySacrectomy
Hemipelvectomy
""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."155
Slide156Rehab Implications7
Type of Procedure/Patient
Surgeon/pt specific restrictions
No sitting (typically x6 weeks)
Getting OOB is more difficult with prone exit
Sidelying
<->Stand transfer
Monitor orthostaticsHOB typically <30 degreesWhen scooting towards HOB using chuck, pt in side-lying to limit pressure on surgical sitePossible ROM restrictionsRequires clearance for toilet/commodeHigh risk for DVT
Clear stair negotiation w/Plastics""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
156
Slide157Orthopedic Considerations
"Managing the Cancer Patient in the Acute Care Setting," 6/14/14, "This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
157
Slide158Bony Mets7,26
Primary cancer site of breast, prostate, lung, kidney, thyroid commonly metastasize to bone
Common locations: axial skeleton,
humerus
, femur, skull, pelvic girdle, ribs
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
158
Slide159Osteolytic lesions
26,27,28
A.K.A.
lytic lesion or osteoclastic lesion“punched out” look
This particular picture is a result of
myeloma
that has invaded the bone and caused the weak areasMyeloma also releases chemicals into the body that lead to this breakdownMost commonly in spine, skull, pelvis, and ribs
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
159
Slide160Osteoblastic lesions
26,29
Induce bone formation and can produce sclerotic vertebral bodies
Growth typically stimulated by tumor
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
160
Slide161MRS. GREEN CASE STUDY
"
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
161
Slide162BONY METASTASIS
>50% cortex involved
No exercise; touch down:
not weight bearing, use
crutches, walker; active
ROM exercise (no twisting)
Plain x-ray findings: high risk indicated by following:
cortical lesions >2.5–3.0 cm;
>cortical involvement;
painful lesions;
unresponsive to radiation
25–50% cortex involved
No stretching, light aerobic
activity; partial weight
bearing; avoid
lifting/straining activity
0–25% cortex involved
Full weight bearing
(7)
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
162
Slide163Modifications of evaluation and treatment7
:
Modify MMT
Modify PROM or AROM
Avoid resistive exercisesAvoid spinal loading with spine mets
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
163
Slide164Pain characteristics that may indicate fracture or impending fracture3
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
164
Slide165Neurological Considerations
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
165
Slide166Spinal Cord Compression
Rehab Considerations
Associated cancers/conditions: metastasis to spine, breast, lung, kidney, prostate, lymphoma,
myeloma
Onset: local back pain, escalates while supine
Progression: paralysis, numbness
Late: loss of bowel/bladder control
Spinal precautions
Monitor changes in bowel/bladder controlAssess and monitor sensations to light touch, proprioception, balance, coordination
(7)
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
166
Slide167(7)
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
167
Slide168Rehab considerations7:
Monitor sensation,
proprioception
, balance, coordination
Safety awareness
Following commands
Avoid
Valsalva maneuvers and keep HOB elevated to at least 30 degrees (to prevent ↑ ICP)Monitor for headaches, nausea, dizziness, ↑ BP"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
168
Slide169Rehab Implications7
Log rolling
BLT (No bending, lifting, twisting)
May need adaptive equipment for ADLs
Room set-upNo Chest PT over spineMets/surgical site
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
169
Slide170Geriatric
Patient
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
170
Slide171Geriatric Statistics20
Cancer is associated with aging
Median age at diagnosis for cancer of all sites was 66 (2006-2010)
Cancer is the leading cause of death among age 60-79
50% of all cancers and 70% of cancer deaths occur in those ≥65From 2010 to 2030, the % of all cancers diagnosed in older adults will increase from 61% to 70%
""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
171
Slide172Geriatric Cancer Patient30
50% of all malignancies occur in the 12% of those 65+
Those 60 and older have a 40-fold risk of developing non-Hodgkin’s lymphoma
Prevalence increases with age in leukemia and cancers of the GI tract, breast, prostate, and urinary tract
Myelodysplastic syndrome (MDS) also appears to occur more in the aging population
""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
172
Slide173Theories30
""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide174(20)
""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
174
Slide175Geriatric Co-morbidities
(20)
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide176(20)
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
176
Slide177Geriatric Syndromes20
Falls
Frailty
PolypharmacyDelirium
Hearing problemsDizzinessFaintingPressure ulcersPainDementia
Vision problems
Malnutrition
Bladder control problems"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."177
Slide178Cancer treatments20
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
178
Slide179Surgery20
Older age is associated with:
worse short-term outcomes after major oncologic resections
higher operative mortality
greater frequency of major complicationsmore prolonged hospital stays"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
179
Slide180MR. BLUE CASE STUDY
"
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
180
Slide181Principles of Rehab20
Cytarabine
– anemia, neutropenia, thrombocytopenia
Induction chemotherapy - myelo-suppression
Idarubicin – CHFNeutropenia – pneumonia, CMVDiarrhea – under nutritionDVT - Lovenox
Foscarnet
- ARF
Atrial fibrillation Orthostatic hypotension""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."181
Slide182Assessment Tidbits20
Musculoskeletal
MMT, ROM
Gait, balance, posture, ADLs
Steroid myopathyimmobilityGVHDCord compression
Surgery
Lymphedema
FractureMetastasisGeriatric Syndromes CardiopulmonaryAuscultation, vital signs6-minute walk (6MWT) or 3MWTBrief fatigue inventory Borg’sSarcopeniacachexia
ADLsRadiation & chemotherapysurgery, anemia, myelosuppresion,Congestive heart failure,
Orthostatic Hypotension
Geriatric Syndromes
"
"Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
182
Slide183Assessment Tidbits20
Neurological
Gait and balance
Vestibular, sensory testing, coordination
ADLsChemotherapyradiationSurgeryMedicationsCNS tumors
Metastasis
Neuropathy
IntegumentarySkin integrityEdemaErythemaPressure ulcersSensationADLsRadiationLymphedemaSurgeryNutritionImmobilityGVHD
""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
183
Slide184When the treatments aren’t working…
Palliative Care – symptom management
Does not necessarily mean end of life, just trying to help prevent readmissions
Hospice Care – 6 months or less time frame
SW 1x/wk, RN 2-3x/wk, HHA 3x/wk 1.5 hrs, nondenominational chaplainWill come to house 24/7 to try and prevent hospital admissionsHospice House – uncontrolled symptoms such as pain, dyspnea, seizures, agitationNot usually there more than 2 weeks – either SNF or home after managed if does not pass while there
GIP – only
medicare
– hospice benefit in the hospitalSame as hospice houseSevere symptom management, not stable enough to move, comfort care, no bed at hospice house ""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."184
Slide185SCOPE
Example: My pain is not being controlled well.
Solve - Let me see if I can get you more medicine.
Criticize - You are already getting a very high dosage. It should be enough.
One-up – You only had knee surgery. At least you didn't have an organ transplant. Probe - How has it changed? What is hurting? Is it sharp, stabbing or dull?Empathize - I'm sorry you're still in pain. I know that procedure can be uncomfortable.
“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide186First Response Tendencies – Pros and Cons
PROS
CONS
SOLVE
Allows you to quickly address patient's issues
You may not have identified the real issue
CRITICIZE
N/A
Elevates emotions or forces patient to withdraw
ONE-UP
When personal, may help you "connect" with patients. Can allay fears
Over time, patient becomes frustrated. Feels he can't "win"
PROBE
Allows you to get the answers you seek
Patient may feel she's being interrogated
EMPATHIZE
Helps to manage patient emotions and open up communication
Can sound insincere if listener is not committed to this approach
“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide187Empathy31 vs. Sympathy32
Empathy – “act of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another…very important in diseases which patient is dependent to the others”
Sympathy – “fellow feeling”, side by side – feeling happy about a success or sad about bad news a friend received
“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
187
Slide188Stages of Grief
Denial and Isolation
Defense mechanism
AngerBargaining“If only we had sought medical attention sooner…”
DepressionSadness and regretPreparation for separation and saying goodbyeAcceptanceWithdrawal and calm – should not be confused for depression
“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
188
Slide189“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
189
Slide190Burnout 32
"a state of emotional and physical exhaustion that results from intense and long-standing professional stress"
"dynamic process that is fed by a negative self-concept and negative job attitudes, which result in a loss of concern for people, a withdrawal from interaction, and
alientation
from the work environment"“Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
190
Slide191Signs and Symptoms of Burnout
Detachment
Compartmentalizing
Less creativityLowering the risk of making a mistakeSelf-dissatisfaction – projected anger and frustration
Marital tensionCompulsive behaviorsPhysical symptoms (headaches, stomach aches, etc)Sleep problems
“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
191
Slide192Why being a Healthcare provider is so hard32
We are responsible for helping people take responsibility for themselves and their health
We have to handle situations when they don't respond to our interventions like we'd hoped
We have to set realistic expectations as we are willing and facilitate change
We have to face the inevitability of terminal illness and death“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
192
Slide193So what can you do?? 32
Alternate work with play
Get some rest!
Read a good bookListen to good music
Learn a new languageFind a confidantJournalMeditateGet out in natureAttend a religious serviceDrink water, exercise, and eat well
“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
193
Slide194Schwartz Rounds
Safe atmosphere for discussing our emotions, dilemmas, successes, and frustrations related to providing patient care
This year they will be on April 11, June 20, August 8, October 17, and December 7.
All Rounds are held in the Suzanne Hill Freeman Auditorium from 12:00 until 1:00 and lunch is provided. Topics of the Rounds are distributed the month prior to each Schwartz Rounds date.
“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
194
Slide195Dilemmas in Acute Care
Educating practitioners and nursing
Appropriate consults and proper timing
Setting goals for patients going home with hospice – are we pushing our patients enough/too much?Are we getting them to the right next level of care?
Difficult to get patients into acute rehab while getting IV chemotherapy while on “chemo vacations”Are we taking their wishes into consideration in our assessments and discharge planning?The pressure to help the patients achieve their goals in order to be able to tolerate another round of chemo
“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide196Discharge Planning 101
How do I know where to send my patients?
What if I am wrong?
How do I educate my patients on the differences in facilities?
How do I keep track of which payor source covers what for my patient?What if I recommend a disposition that their insurance won't cover?What if I recommend rehab and they send the patient home? Should I change my note?
“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide197Medicaid
Always think “long term” in terms of SNF and ALF coverage
Will not pay for short term rehab or reimburse for HH or OP therapy
Patient must be in a SNF for 30 days for SNF to be reimbursed (patient’s income i.e. SSI check)
Qualifications for Medicaid65 and older with low incomeUnder 65 but disabled with low incomeOr you have kids
“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide198Medicare A, B, C
Medicare A
Medicare B
Medicare C
–
commercial insurance plan
Days 1-20: patient pays $0 for each benefit period (benefit period
ends when you have not been an inpatient in a hospital or at a SNF for 60 days in a rowDoctor’s office visits, OPPT, DME, Observation status in the hospital Takes over everything
Days 21-100: Patient/secondary insurance responsible for $161/day (2016 rate), patient coinsurance 20% (Medicare pays 80%) for each benefit period
3 night inpatient stay is sometimes
needed (OBS may be okay) however some SNFs have contracts that allow them to admit patients without a 3 night stay
Days 101 and beyond: Patient responsible for all costs
Also why it can
be difficult to get a patient with this plan into rehab (CR or SNF) because they require commercial insurance authorization (PT and OT notes) whether OBS or INPT
No prior authorization
needed
Prior authorization
is usually needed however some SNFs have contracts that allow them to admit patients prior to authorization (only 1 SNF can submit for authorization at a time)
3 night inpatient stay needed
Examples include: Advantage, Humana, BCBS, Aetna, UHC
If you are away from the SNF LESS than 30 days, you do NOT need a new 3-day hospital stay to qualify
“Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide199End of Life dispositions
Comfort Care
Hospice
House
GIP
SNF
–
medicare will cover hospice services only, not room and board Uncontrolled symptoms to manage (pain, breathing, etc)
Hospice house in hospital Medicaid – pay long term care
Only a short
term option
Hospital MD has to agree to be attending for patient while in house
Medicaid/Medicare only
–
no commercial
insurance
“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide200LTAC and Out-of-state
LTAC
Okay for Medicare
– does not need authorizationHas to have three medical needs (wound care, dialysis, IV
abx)Some plans have LTAC benefits and others don’t SC vs. NCIt is easier for NC patients to go to SC facilities than it is for SC patients to go to NC facilitiesIf they only have Medicaid, they can only go within their state
However, if they have Medicare (federal level) they can go anywhere
“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
Slide201Final Case Studies
“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
201
Slide202Case Study #1
86
yo
M presents to the ED with 103 degree temp, 121 HR, BP 80/35. Fever was the main for admission. Wife reports he became more confused as day went on, which she says is typical, but he usually falls asleep around 9. Was not able to sleep and growing more confused, she grew concerned and took his temp. Reports he has been feeling more poorly within the last week and has been spending a lot of time in the bed or in his recliner. He has a history of COPD and is on 2L O2 mainly at night with a 100 pack year history, but reports he quit 2 years ago.
"“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
202
Slide203Case Study #1 cont’d
Additional labs were K+ 2.9,
creatinine
of 1.57, and a lactate of 6.5. He was started on
levophed, IV fluids, and vancomycin and zosyn. CT chest showed B pleural effusions, bone, peritoneal and liver mets
. Blood and urine cultures (-).
Also has a history of stage IV adenocarcinoma of bile duct s/p Whipple, R breast CA s/p R mastectomy currently on chemotherapy, and advanced prostate cancer.
He is on steroids prednisone and abiraterone (used to treat prostate cancer that has spread in combination with prednisone).Consult was written for PT consult due to fatigue and weakness. Differential diagnosis?“Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
203
Slide204Case Study #2
66 year old active male presents to the ED with back pain at rest, at night, and with movement and an unintentional weight loss of 30
lbs
over the last 3 months. He enjoys going to the gym, using the weight machines, and golf. The back pain was initially noticed 4 months ago after a round of golf but was intermittent at that time. He presents to the ED now because he can no longer play golf, sit long enough to finish a television show, and can barely tolerate driving. He does report a L4-5 laminectomy 1.5 years ago with resolution of LE symptoms after recovery. Reports one accidental slip and fall coming out of his garage on a rainy afternoon 1.5 months ago.
"
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
204
Slide205Case Study #3
70 year old female presents with altered mental status, nausea/vomiting, and hypotension 98/65. She has a history of lung cancer and ongoing chemotherapy treatments. Labs come back and her Na+ is 133
mEq
/L. She also has a history of HTN, ischemic R MCA CVA with residual L hand
paresthesias, as well as type II DM. She does report two falls in the last month and that she currently does not have any adaptive equipment at home.
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
205
Slide206Case Study #4
52 year old male who presents with weakness due to decreased appetite, vomiting and diarrhea. Newly diagnosed AML in second chemotherapy cycle. Also reports tingling and palpitations. Labs reveal K+ is 2.4mmol/L. Has a remote cardiac history of a mild NSTEMI two years ago after a car accident and is on a low dose beta blocker. Was a borderline diabetic prior to AML diagnosis.
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
206
Slide207Case Study #5
63 year old female admits from her primary care physician’s office where she presented with bone pain, muscle weakness, urinary frequency, and nausea. Reports she hasn’t been as active in the last couple of weeks due to extreme fatigue. Had routine lab work completed while there and they revealed Ca2+ 10.4mg/
dL
so she was sent to the hospital. Reports several “near falls” where she grabbed onto the sofa, a chair, the wall and was able to “sit quickly.” Doesn’t use an assistive device because that is for “old people.” Lives in a second floor apartment with a roommate who still works during the day. Was independent prior to admission. Her children live in Virginia.
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
207
Slide208Case Study #6
48 year old female presents to ED three weeks into her first chemotherapy cycle with a fever of 101 for over an hour and an ANC 700. Husband reports some brief confusion and mild SOB with activity over the last couple days. Patient also reports she has seasonal allergies and asthma so she didn’t call her doctor right away.
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
208
Slide209Case Study #7
65 year old male, newly retired, presents to the ED with reports of night sweats, unexplained fevers, unintentional weight loss of 30
lbs
in 1.5 months, and bruising easily. CBC done and revealed: WBCs 50,000,
Hgb 7.0, and platelets of 89,000. Reports his wife told him he needed to start exercising more and had just recently begun a workout program at the YMCA. His wife then became concerned that he was losing too much weight and had him take a break from the YMCA. He then began sleeping most of the day and not having his “normal energy.” She began noticing bruises on his arms and legs but had not remembered any falls or accidents to cause them.
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
209
Slide210Case Study #8
52 year old female diagnosed with AML in 2015, allogeneic transplant in 2016 after multiple cycles of chemotherapy. Presents to hospital after a fall while trying to fix her lawnmower. Imaging shows acute fractures of the R talus and calcaneus as well as distal 1-3 metatarsals. Also shown that she has an acute
nondisplaced
fracture of the L superior/inferior pubis
ramis and L hemisacrum. She has been seen by the orthopedic doctor who gives her the WB status as follows: R NWB in a walker boot and L WBAT.
"Managing the Cancer Patient in the Acute Care Setting," 6/14/14, "This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
210
Slide211References
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Miskovitz
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Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
212
Slide213References
36. http://
www.lls.org
/treatment/types-of-treatment/stem-cell-transplantation/graft-versus-host-disease; Accessed 9/29/16
37. VR Bhatt, GM Viola et al. Invasive fungal infections in acute leukemia. Ther Adv Hematol
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http://www.lymphoma.org/site/pp.asp?c=bkLTKaOQLmK8E&b=6300155; Accessed 9/25/1639. Narayanan G, Pezeshkmehr A, et al. Safety and Efficacy of the PleurX Catheter for the Treatment of Malignant Ascites. J Palliat Med. (2014) Aug 1; 17(8) 906-912. 40. Chao NJ. Clinical Manifestations, diagnosis, and grading of acute graft-versus-host disease. UpToDate 2016. https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-grading-of-acute-graft-versus-host-disease/print
. 41. Klassen J. The Role of Photophoresis in the Treatment of Graft-Versus-Host Disease. Current Oncology
. (2010)
Vol
17 (2) 55-58,
42. Uterine cancer types.
http://www.cancercenter.com/uterine-cancer/types/tab/endometrial-cancer/
; Accessed 10/24/16.
43. Sepsis.
http://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/dxc-20169787?p=1
; Accessed 10/26/16.
44. Ovarian Cancer.
http://www.mayoclinic.org/diseases-conditions/ovarian-cancer/basics/definition/con-2002
; Accessed 10/24/16.
45. Colon Cancer.
http://www.mayoclinic.org/diseases-conditions/colon-cancer/symptoms-causes/dxc-2018
; Accessed 10/24/16.
46. Pancreatic Cancer.
http://www.mayoclinic.org/diseases-conditions/pancreatic-cancer/basics/definition/con-2
; Accessed 10/24/16.
47. Liver Cancer.
http://www.mayoclinic.org/diseases-conditions/liver-cancer/symptoms-causes/dxc-20198
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48. Kidney Cancer.
http://www.medicinenet.com/kidney_cancer/article.htm
; Accessed 10/26/16.
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https://medlineplus.gov/lungcancer.html
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"“
Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
of the author."
213
Slide214References
53
.
http://www.hopkinsmedicine.org/kimmel_cancer_center/centers/bone_marrow_transplant/donor_lymphocyte_infusions.html
; Accessed 11/3/16 8:58AM54.http://www.leukemiabmtprogram.org/patients_and_family/treatment/blood_and_marrow_transplant/donor_leukocyte_infusion.html;Accessed 11/3/16 9:04AM55. http://www.bloodworksnw.org/therapy/cryo.htm
; Accessed 11/3/16 9:07AM
56.
http://www.bloodworksnw.org/therapy/ffp.htm;Accessed 11/3/16 9:14AM57. http:www.cancer/gov/types/lymphoma/patients/aids-related-treatment-pdq; Accessed 10/20/16 and 11/7/16 4:00PM."Managing the Cancer Patient in the Acute Care Setting," 6/14/14, "This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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Slide215Contact Me
Katie.Tasillo@carolinashealthcare.org
704-355-2382
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Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."
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