10:59 PM
Kira
Cancer- are mutated stem cells that have undergone structural changes so that they are unable to perform their normal functions
Anatomy and physiology of a cell
- Nucleus – RNA/CHON synthesis= cell metabolism= give antimetabolites- to destroy cell metabolism and RNA/CHON synthesis
- MTX, 6 MP = antidote- 5 FU= antogonistic- dec folic acid= anemia
- Chromatin – threadlike material for DNA synthesis= cell replication/multiplication= give alkylating agent= destroy cell multiplication/replication
- 1. Cytoxan, Cisplatin= hemo cystitis= inc fluid intake, frequent emptying of the bladder
- 2. Plant alkaloid- Vincristine, Vinplastin/ oncovin – nephrotoxicity= constipation and paresthesia=s/e
Classification:
- Benign- grow slowly, not life threatening/glandular adenoma,bone osteoma,nerve cell neuroma,fibroma
- Malignant- infiltrate surrounding tissue, invade other tissues and produce secondary lesions/adenocarcinoma, carcinoma,sarcoma,melanoma
- American Cancer Society Warning Signs
- Change in bowel, bladder habits
- A sore that does not heal
- Unusual bleeding or discharge
- Thickening or a lump in the breast or elsewhere
- Indigestion or difficulty in swallowing
- Obvious change in a wart or mole
- Nagging cough or hoarseness
Causative Factors
- Physical- radiation- excessive exposure to sunlight and radiation/ chronic irritation
- Chemical- food additives- nitrates/ industry- asbestos/pharmaceuticals-stilbesterol/ smoking/alcohol
- Genetic
- Viral- Epstein-Barr virus/ Burkitt’s lymphoma
- Stress
Diagnostic Procedures and Labs.
- X- rays
- CAT scan – non invasive, during the patient will lie still- for 1-11/2 H
- Cytology – cell study, invasive, sterile technique, monitor baseline V/S, after apply pressure
- Radioisotope scan – introduction of radioisotope tracer into the client’s vein- to determine = organ perfussion determination
- MRI
- Mammography- baseline at 35-45 yrs old- no deodorants
- Lymphangioraphy – introduction of dye into web of foot to det tumor stage and involvement
- Colposcopic exam of the cervix – invasive, informed consent, ibuprofen b4 procedure to stage tumor= cancer in SITU- confines to cervical lining only, stage 2 entire cervix, 3 upper 2/3 of vagina, 4 lower 1/3 of vagina, 4 bladder and rectum
- Bone marrow biopsy –infants = tibia, adult post iliac crest, invasive
- Hematology
TUMOR marker
- PSA – 4mg/dl N---8 BPH---10 prostate ca
- Inc ALP – prostate, bone and liver ca
- CA 125 / cancer Ag 125= ovarian ca
- CEA- carcinoembryonic antigen = colon, rectal, breast and lung ca
- AFP- alpha feto CHON – inc= testicular ca
6. HCG
7. CA 19-9 = GIT ca
8. CA 15-3 = breast ca
9. NSE- neuron specific enolase – neuroblastoma
Stages of Tumor growth
N – stands for lymph node involvement
M – stands for metastasis
2. Satges 0-IV
Early detection:
- Seven warning signs
- BSE
- Rectal exam -40 y/o
- Hazards of smoking
- Oral self examination-annual mouth and teeth
- Hazards of excess sun exposure
- Pap smear
- Physical exam 30 y/o Q 3 years, over 40 yearly
Classification
- Carcinoma- epithelial tissue
- Sarcoma- connective tissue
- Lymphoma- lymphoid tissue
- Leukemia – blood forming- tissue( WBC’s and platelets)
Alkylating agents- interferes with rapidly reproducing cell DNA | Side effects | Nursing considerations |
Busulfan/Myleran Cisplatin | Bone marrow depression, tremors, confusion, hepatotoxicity | Check CBC Extra fluids to flush system |
Chlorambucil/Leukeran | N/V, bone marrow depression, sterility | Monitor for infection Avoid IM injection when platelet is low |
Cyclophosphamide/Cytoxan | Alopecia, bone marrow depression, hemorrhagic cystitis, dermatitis, hyperkalemia, hypoglycemia, amenorrhea | Report hematuria, force fluids Monitor for infection Give antiemetics |
Antimetabolites | ||
Fluorouracil ( 5-FU ) | Nausea, stomatitis, GI ulceration Diarrhea, bone marrow depression, liver dysfunction,alopecia | Monitor for infection, avoid extravasation |
Methotrexate/MTX | Oral and GI ulceration,liver damage,bone marrow depression, stomatitis, alopecia,bloody diarrhea, fatigue | Good mouth care, avoid alcohol,monitor hepatic and renal function tests |
Mercaptopurine/6 MP | Liver damage,bone marrow depression, infection, alopecia, abdominal bleeding | Check liver function tests |
Cytarabine | Hematologic abnormalities,nausea,vomiting,rash, weight loss | Force fluids, good oral hygiene |
Hydroxyurea/Hydrea | Bone marrow depression, GI sx, rash | Teach client to report toxic GI sx promptly |
Antibiotics-antineoplastics | ||
Doxorubirin/Adriamycin | Red urine, N/V, stomatitis, alopecia, cardiotoxicity, blisters, bone marrow depression | Check ECG, avoid IV infiltration, monitor V/S closely, good mouth care |
Bleomycin/Blenoxane | N/V, alopecia,edema of hands,pulmonary fibrosis,fever,bone marrow depression | Observe for pulmonary complications,treat fever with acetaminophen, check breath sounds |
Dactinomycin/ Actinomycin D | Nausea, bone marrow depression | Give antiemetic before administration |
Vinca Alkaloids- interfere with cell division | ||
Vincristine/Oncovin | Peripheral neuritis, loss of reflexes, bone marrow depression, alopecia, GI sx | Check reflexes, motor and sensory function, give zyloprim, avoid IV infiltration |
Vinblastine/Velban | N/V, stomatitis, alopecia, loss of reflexes, GI sx | Avoid IV infiltration andextravasation, give antiemetic before administration, acute bronchospasm can occur if given IV, Zyloprim given to increase excretion and decrease buildup of urates |
Hormonal Agents- changes hormone input into sensitive cells | ||
Tamoxifen/Nolvadex | Transient fall in WBC or platelets, hypercalcemia, bone pain | Check CBC, monitor serum calcium, nonsteroidal antiestrgen |
Implementation:
A. Radiotherapy
- External radiation( cobalt)
- Leave markings intact on skin
- Avoid creams or lotions, deodorants, perfumes ( vit A and D ointment permitted)
- Use lukewarm water to cleanse the area
- Assess skin for redness, cracking
- Administer antiemetics for nausea, analgesics for pain
- Observe skin, mucous membrane,and hair follicles for side effects
- No hot water bags, bottles,tape, don’t expose area to cold or sunlight
- Internal radiation ( cesium, radium, gold
- Wear cotton clothing
Internal radiation ( cesium, radium, gold
- Sealed source- mechanically positioned source of radioactive material placed in body cavity or tumor
- Lead container and long-handled forceps in room in event of dislodged source
- Save all dressings, bed linens until source is removed, then discard dressings and linens as usual
- Urine, feces, and linens not radioactive
- Do not stand close or in line with radioactive source
- Patient on bedrest while implant in place
- Position of source verified by radiography
b. Unsealed Source- unsealed liquid given orally or instilled in body cavity, all fluids are contaminated, greatest danger from body fluids during the first 24-96 hours
- Assign patient to private room
- Place”Caution: Radioactive Material” sign on door
- Wear dosimeter film badge at all times when interacting with patient( offers no protection but measures amount of exposure)
- Do not assign pregnant nurse to patient
- Rotate staff caring for patient
- Organize tasks
- limit visitors
- Encourage patient to do own care
- Provide shield in room
- Use antiemetics
- Provide comfort measures, analgesics for pain
- Provide good nutrition
B. Skin care
- Avoid use of soaps, powders, lotions
- Wear cotton clothing, loose-fitting
C. Mouth care
- Stomatitis – develops 5-14 days after chemo
- Symptoms- erythema, ulcers, bleeding
- Oral rinses with saline or soft bristled toothbrush
- Avoid hot( temperature) or spicy foods
- Topical antifungals and anesthesia
D. Hair care
- Alopecia commonly seen, alters body image
- Assist with wig or hair piece, scarves, hats
E. Nutritional changes
- anorexia, nausea and vomiting
- Malabsortion and cachexia common
- Make meals appealing to senses
- Conform diet to client preferences and nutritional needs
- Small frequent meals with additional supplements between meals( high calorie, high CHON )
- Encourage fluids but limit at meal times
- Perform oral hygiene and provide relief of pain before meal time
- TPN as needed
- TPN as needed
- Pain relief- 3 step ladder approach
- For mild pain- non narcotic meds used ( Tylenol ) along with antiemetics, antideppressants, glucocorticoids
- For moderate pain- weak narcotics ( codeine) and nonnarcotics
- Severe pain- strong narcotic ( Morphine)
- Give pain meds on regularly schedule basis ( preventive approavh) additional analgesics
G. Activity level
- Alternate rest and activity
- Maintain normal lifestyle
H. Psychosocial Issues
- Encourage participation in self-care and decision making
- Provide referral to support groups, organization
- Hospice care
- Chemotherapy
Principles- based on ability of drug to kill cancer cells
- antimetabolites- foster cancer cells death by interfering with cellular metabolic process
- Ankylating agents- act with DNA to hinder cell growth and division
- Plant alkaloids- obtained from the periwinkle plant, makes the host’s body a less -antitumor antibiotic- affects RNA to make environment less favorable for cancer growth
- favorable
- Steroids and sex hormones- alter the endocrine environment to make it less conducive to growth of cancer cells
Major Side effects/ Nursing Care
- GI/ nausea and vomiting
- Antiemetics- every 4-6 H
- Withold fluids/foods 4-6 H before chemo
- Bland diet- in small amount
2. Diarrhea- administer antidiarrheals
- Maintain good perineal care
- Give clear liquids as tolerated
- Monitor K, Na and Chloride levels
Stomatitis- teaching for oral good hygiene, avoid commercial mouthwash
- Rinse with viscous lidocaine before meals
- Perform a cleansing rinse with plain water
- Advise client to suck on Popsicles to provide moisture
3. Thrombocytopenia- avoiding bumping or bruising skin
- Protect from injury
- Avoid aspirin products
- Avoid giving IM injections
- Monitor blood count carefully
- Assess for and teach of increased bleeding tendencies
4. Leukopenia- careful handwashing, assess respirtory infection, avoid crowds
5. Anemia- rest periods, monitor hemoglobin and Hct, protect from injury, administer oxygen
6. alopecia- explain that hair loss is temporary, offer support and encouragement
- Scalp tourniquet or scalp hypothermia via ice pack may be ordered to minimize hair loss with some agents
- Wigs
7. Renal system
- Fluids
- Zyloprim
8. Reproductive system
- Reliable methods of conception
9. Neurologic system
- Peripheral neuropathies, loss of deep tendon reflexes, paralytic ileus
BONE MARROW TRANSPLANT- alternative treatment for severe aplastic anemia, etc.
Types:
- Autologous- client transplant with own harvested narrow
- Syngeneic – transplant between identical twins
- Allogeneic- transplant from genetically nonidentical donor- sibling -common
- Donor suitability determined through tissue antigen typing, includes human leukocytes antigen and mixed leukocyte culture typing
- Donor bone marrow is aspirated from multiple sites along the iliac crests under general anesthesia
- Donor marrow is infused IV into the recipient
Early evidence of engraftment seen during the second week posttransplant, hematologic reconstitution takes 4-6 weeks, immunologic reconstitution takes months
Hospitalization of 2-3 months required
Prognosis is highly variable
Complications:
- Failure of engraftment
- Infection- highest 2-3 weeks, pneumonia
- Graft vs. host disease- principal complication
- acute GVHD – develops in first 100 days post transplant and affects the skin, GUT, liver, marrow and lymphoid tissue
- chronic GVHD- develops 100-400 days post transplant, manifested by multiorgan involvement
-recurrent malignancy
-late complications- cataracts, endocrine abnormalities
Care/Pretranplant:
- Recipient immunosuppression attained with total body irritation and chemotherapy to eradicate existing disease and create space in host marrow to allow transplanted cells to grow
- Client should be in laminar air flow room or in strict reverse isolation surveillance,cultures done 2x a week
- Objects must be sterilized
- When working with children introduced new people where they can seen
- Monitor central line frequently, patency and observe for signs of infection
- Provide chemotherapy and radiation therapy
Posttransplant
- Maintain protective environment, administer antibiotics, wound culture, V/S, change IV sets Q 24 H
- Provide mouth care- note bleeding, sloughing off
- Do not use lemon and glycerin swabs.
- Administer parental narcotics as ordered if necessary to control pain.
- Provide care every 2 hours or as needed
- Provide skin care: breakdown may result from profuse diarrhea from TBI.
7 . monitor carefully for bleeding.
8. check for occult blood in emesis and stools.
9. observe for easy bruising , petechiae on skin, mucous membranes.
10. check platelet count daily.
11. replace blood products as ordered (all blood products should be irradiated).
12. maintain fluid and electrolyte balance and promote nutrition.
13. measure I&O carefully.
14. provide adequate fluid, protein and caloric intake.
15. weigh daily.
16. administer fluid replacement as ordered.
17. monitor hydration status: check skin turgor, moisture of mucous membranes, urine output.
18. check electrolyte daily.
19. administer antidiarrheal and agents as needed.
20. provide client teaching and discharge planning concerning
20. Medication regimen: schedule dosages, effects, and slide effects
21. communicable diseases and immunizations
22. daily hygiene and skin care
23. fever.
24. activity.
STAGES OF CANCER TREATMENT
- Induction: goal- to remove the bulk of tumor
method- surgery, radiation, chemotherapy, transplant
effect- often the most intensive phase, s/e are potentially life threatening
B. consolidation- goal- to eliminate any remaining malignant cells
- method- chemo/radiation
-effects – s/e still be evident
C. Maintenance- goal- to keep child disease free
-method- chemo-lasts for several years
D. observation- goal- to monitor the child at intervals for evidence of recurrent disease and complications of treatment
-method- tx. Is complete
E. Late effects of tx.
-impaired g/d, CNS damage, development of secondary malignancy, psychologic problem
TYPES:
Skin cancer-Risk factors: sunlight 10 am-3 pm, chemicals, immunosuppression
Basal cell carcinoma- most common
- small, waxy nodule on sun-exposed area of body, may ulcerate and crust
Squamous cell carcinoma- rough thick, scaly tumor seen on arms or face
Malignant carcinoma – variegated color ( brown, black with gray or white ) circular lesion with irregular edges seen on trunk or legs
- most lethal, high risk with fair complexion, blue eyes, red or blonde hair, freckles
Cardinal sx: asymmetry, border irregularity, change in color, diameter inc
TX: surg resection, radiation, chemo, immunotherapy
Intracranial Tumors/Brain CA
S/S- motor deficits, hearing difficulties, dizziness, paresthesia ( cerebellum), N/V, seizures ( motor cortex),visual disturbances ( occipital lobe), drowsiness, change in LOC
Risk Factors: radiation, hereditary, cong immune deficiency
Cardinal sx: depends on the site
cerebellar area = most common site/ risk 4 injury
Pons – respiratory center/ineffective breathing pattern
Medulla – cardiac and visceral organs
Sp. Cord – bowel/bladder/sensation of the lower extremities
frontal lobe- altered though process
EYE CA
Retinoblastoma- children, hereditary – cause
Cardinal sx: white pupillary reflex, LEUKOCORIA/ cat’s eye reflex
TX: Upera- enucleation wid implant of prosthesis, radiation
EARS CA
acoustic (CN 8) neuronoma- benign
motor – vestibules, balance, vomiting, vertigo,
accessory – cochlear- tinnitus, ringing of the eras, hearing loss
TX: UR
ORAL CA
mouth or buccal mucosa
Risk Factors: alcohol, cigarette, exposure to sun
Cardinal sx: a sore that doesn’t heal- LEUKOPLAKIA- white patches in the buccal mucosa
TX: URC
THYROID CA
3 F’s female, 15 young, family hx
Cardinal sx: palpable mole in the thyroid, painless LN enlargement, pain during swallowing and breathing
TX: UR
LARYNX CA
Risk Factors:3 F’s father, forty, frequent smoking and alcohol intake, straining of voice
Cardinal sx: hoarseness of voice, dyspnea, dysphagia
TX: U- laryngectomy R
ESOPHAGUS CA
Risk Factors: Smoking, Alcoholic, Male
Cardinal sx: dysphagia, or difficulty in swallowing
TX: URC
Exogenous estrogen use/Premarin
CANCER OF THE STOMACH
-Cause by excessive intake of highly salted or smoked foods, diet low in quantity of vegetable and fruits, helicobacter pylori infection, achlorhydria, atrophic gastritis
-RISK Factors: highly colored smoked food/salty food, alcohol, ELLISON_SOLINGER syndrome ( pancreas secrete Gastrin- secreting tumor), blood type A, diet low in vegs and fruits
-Cardinal sx: indigestion/dyspepsia
-TX: Billroth I and II
RENAL CA= Wilms tumor, Renal cell ca
Risk Factors: Renal cell ca occurs bet 50-70 years old
Exposure to contrast medium and gasoline
Nephroblastoma occurs at 2-4 y/0/Wilm’s
Asbestos exposure
Lalaki common/ male
Cardinal sx: RCC= Palpable mass
Painless hematuria
Pain in the flanks
Wilm’s= abdominal enlargement, NO palpation and biopsy
narcotic, anti emetic, antacid, surgery- rem of pancreas/ whipples
CANCER OF THE COLON/RECTUM
-Risk Factors:Family hx of ca, age 50 and above, Turgot’s syndrome ( polyps at rectal and GI ), Hx of bowel inflam disease/ ulcerative colitis, Excessive red meat and fat intake, Resected colorectal ca
-ADENOCARCINOMA is the most common type of colon cancer
- men and women 50-60 years old
- Cardinal SX: alteraltion bowel pattern, stool characteristic ( PENCIL LIKE), chronic bleeding and anemia
-caused by diverticulitis, chronic ulcerative colitis, familial polyposis
-S/S – alternating diarrhea, constipation, lower abdominal cramps, abdominal distension, weakness, pallor, anorexia, weight loss, dyspnea
-dx. Test- barium enema, sigmoidoscopy, digital rectal exam
LUNG CA
Risk Factors: cigarette smoking, exposure to chemicals, pulmonary irritation and environmental pollution
Cardinal sx: nagging cough, dyspnea, impaired gases-diminished BS, hemoptysis
TX: URC
Risk Factors: Cigarette smoking
Chemicals
Common in men
Cytoxan
Cardinal Sx: painless hematuria
TX: U- cystectomy= post urinary diversion – Ileal conduit
PANCREATIC TUMOR
Risk Factors:
Pancreatitis- autodigestion of pancreas
Alcohol
Nutritional def
Chemicals
Rate of moratality is very high
Excessive fats
Age above 60
Smoking
Cardinal sx: indigestion,trauma
S/S- weight loss, vague upper or mid-abdominal discomfort, abnormal glucose tolerance test, jaundice, clay colored stools, dark urine
- Whipple procedure- removal of head of the pancreas, distal portion of the common bile duct, the duodenum and part of the stomach
- complication = hypoallergenic shock- oliguria
CANCER OF THE LIVER- common site for metastasis
Risk factors: Metastasis from other organ,Alcohol and Aflatoxins ( green bread), Cirrhosis and Hep B and C, Africans, Asians, americans, Oral contraceptive pills
Cardinal Sx: indigestion, dyspepsia
- S/S- enlargement of the liver, hemorrhage, necrosis are common, metastasis to the lungs
- highly in men
LEUKEMIA- most common cancer in childhood
- proliferation of abnormal white blood cells that do not mature beyond the blast phase
- in the bone marrow, blast cells crowd out healthy white blood cells, red blood cells, and platelets, leading to bone marrow depression
- symptoms reflect bone marrow failure and associated involvement of other organs
Types:
- ALL- lymphocyte, acute onset, 75 % chance of survival, WBC 10,000/mm3 less than-2-9 y/o
-ANLL- includes granulocytic and monocytic types
S/S- Acute myeloid leukemias Lymphadenopathy
- AUER rods Excessive weight loss
found only Unusual bleeding/ epistaxis
Knee and joint pain
Enlarged abdomen
Malaise
Infection signs, fever, sore throat, stomatitis
Anemias, severe
ALL = Genetics
Exposure to Benzene or gasoline
Excessive alkylating agents
T- lymphoma virus
Ionizing radiation
Caucasian children
Cardinal sx: unusual bleeding or d/c
BREAST CANCER- leading cause of death – 40-44 y/o for women
Risk Factors:
Advancing maternal age
Breast ca hx
Cigarette smoking and oral intake of contraceptive pills
Diet increase in fats
Early menarche and late menopause
First child after 35 years old or nulliparity
Cardinal sx:– palpation-lump- upper outer quadrant- common site- first symptom
- skin of breast dimpled, nipple discharges, asymmetry of the breast,
BREAST SELF-EXAMINATION
- after period – best time
- HOW- lie down and put a pillow under your R shoulder. Place your R arm behind your head
- use the finger pads of your 3 middle fingers on your L HAND TO FEEL FOR LUMPS OR THICKENING.Your finger pads are the top thirds of each finger
-Press firmly enough to know your breast feels. A firm ridge in the lower curve of each breast is normal
- Move around the breast in a set way; CIRCLE, UP AND DOWN, OR THE WEDGE. Do it the same way at each time
CANCER OF THE CERVIX- detected by Pap smear
- class I – normal pap smear
- class II – atypical cells
- class III – moderate dysplasia
- class IV – severe dysplasia, cancer in situ
- class V – squamous cell carcinoma, invasive cancer
Preinvasive conditions maybe treated by cryosurgery, laser surgery, cervical conization, or hysterectomy
Invasive conditions- treated with radium and hysterectomy
CANCER OF THE UTERUS
- cardinal symptom- abnormal uterine bleeding either pre or post-menopause
CANCER OF THE OVARY
- ETIOLOGY: UNKNOWN
- ovarian mass during palpation
- now, examine your L breast using R finger pads using same procedure
- if you find changes, see your doctor immediately
Risk Factors:
Ovarian dysfunction/ amenorrhea
Vague abd’l sx, n/v
Age, above 50
Race , whites
Incidence, inc with + hx
Alcohol
Nulliparity
Cardinal Sx: Amenorrhea, Abd’l enlargement, Ascites, Abdominal bloating
TX: U- oophorectomy= ERT
ENDOMETRIAL CA
Risk Factors: Multiple use of Tamoxifen Cardinal sx:bleeding irreg
Early menarche
Nulliparity tx: u- TAHBSO
Obesity
Post menopausal
Age 55 above
Urban living
Sex: F/ sex multiple
BONE CA
Risk Factors: inherited genes ( osteo, sarcomas), radiation tx. (Radium = bone demineralization) Paget’s dis., secondar cause of cancer
Cardinal sx: Bone fx, Occassional fatique- intermittent, pain worsens at nite, Nocturnal pain, Edema/swelling/lump
Tx: URCHIB
LUNG CA
Risk Factors: cigarette smoking, exposure to chemicals, pulmonary irritation and environmental pollution
Cardinal sx: nagging cough, dyspnea, impaired gases-diminished BS, hemoptysis
TX: URC
Risk Factors: Cigarette smoking
Chemicals
Common in men
Cytoxan
Cardinal Sx: painless hematuria
TX: U- cystectomy= post urinary diversion – Ileal conduit
PROSTATE CA
Risk Factors: Family hx Cardinal SX : frequency
African American residual urine
Men eval of uria flow decrease
Age over 65 hesitancy
STD’s/ smoking nocturia
TX: U = Horse +R+C small urinary stream
hormonal manipulation
orchiectomy, bilateral, over 70 no tx
radical prostatectomy, counselling cause impotence
SILDENAFIL/ Viagra, Saw Palmetto Berry
Extrenal beam/interstitial radiation
TESTICULAR CA
Risk Factors: 15-39 y/o
undescended testicles
TSE- HS
Cardinal sx: 4 L’s: Lump, pea sized
Loaded heavines radiation to scrotum and groin
Leg pain
Large/obese
TX: U- inguinal orchiectomy
R- lymphatics
Cisplatin/Platinol
Risk Factors: 15-39 y/o
undescended testicles
TSE- HS
Cardinal sx: 4 L’s: Lump, pea sized
Loaded heavines radiation to scrotum and groin
Leg pain
Large/obese
TX: U- inguinal orchiectomy
R- lymphatics
Cisplatin/Platinol
Risk Factors: cause unknown, young males, Epstein Barr virus
Cardinal SX: supraclavicular node, painless, nigth sweats, flu like sx
TX: U -splenectomy= LN dissection/ biopsy 4 Reed-Sternberg cells
R – com of alkylating and plant alkaloids= MOPP
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