Ch. 15 Oncology: Nursing Management in Cancer Care

Nursing Management in Chemotherapy

Assessing fluid, electrolyte status Assessing cognitive status Modifying risks for infection, bleeding Administering chemotherapy Protecting caregivers

Cancer

Disease process that begins when abnormal cell is transformed by genetic mutation of cellular DNA

Palliative surgery

when surgical cure is not possible, the goals of surgical interventions are to relieve symptoms, make the patient as comfortable as possible, and promote quality of life as defined by the patient and family.

*Altered Nutrition: Nausea and Vomiting

Assess patient's previous experiences, expectations of nausea and vomiting, including causes, interventions used Adjust diet before, after drug administration according to patient preference, tolerance Prevent unpleasant sights, odors, sounds in environment Use distraction, music therapy, biofeedback, self-hypnosis, relaxation techniques, guided imagery before, during, after chemotherapy Administer prescribed antiemetic, sedatives, corticosteroids before chemotherapy, afterward as needed Ensure adequate fluid hydration before, during, after drug administration; assess intake, output Encourage frequent oral hygiene Provide pain relief measures if necessary Consult with dietician as needed Assess, address other contributing factors to nausea, vomiting

*Impaired Skin Integrity: Erythematous Areas

Avoid use of soaps, cosmetics, perfumes, powders, lotions and ointments, deodorants Use only lukewarm water to bathe area Avoid rubbing or scratching area Avoid shaving area with straight-edged razor Avoid applying hot-water bottles, heating pads, ice, adhesive tape to area Avoid exposing area to sunlight or cold weather Avoid tight clothing in area; use cotton clothing Apply vitamin A and D ointment to area

Which type of surgery is being done when lesions that are removed are likely to develop into cancer? A) Diagnostic B) Palliative C) Prophylactic D) Reconstructive

C) Prophylactic Rationale: The type of surgery being done when lesions that are removed are likely to develop into cancer is called prophylactic surgery. Diagnostic surgery such as a biopsy is usually performed to obtain a tissue sample for analysis of cells suspected to be malignant. Palliative surgery is performed in an attempt to relieve complications of surgery. Reconstructive surgery is carried out in an attempt to improve function or obtain a more desirable cosmetic effect.

Which measure should the RN not teach a client about protecting the skin between radiation treatments? A) Handle the area gently. B) Avoid irritation with soap and water. C) Use a heating pad every day on the area. D) Wear loose fitting clothes.

C) Use a heating pad every day on the area. Rationale: Measures to protect a client's skin between radiation treatments include handling the area gently, avoiding irritation with soap and water, and wearing loose-fitting clothing. The client should not use a heating pad every day on the area because it will not promote tissue repair.

Radiation therapy

CURATIVE- may be used to cure cancer, as in thyroid carcinomas, localized cancers of the head and neck, and cancers of the cervix. CONTROL- used to control cancer when a tumor cannot be removed surgically or when local nodal metastasis is present- used to reduce tumor size in order to facilitate surgical resection PALLIATIVE- used to relieve the symptoms of metastatic disease, especially when the cancer has spread to the brain, bone, or soft tissue, or to treat oncologic emergencies, such as superior vena cava syndrome, bronchial airway obstruction, or spinal cord compression

Characteristics of Benign and Malignant Neoplasms

Cell characteristics Mode of growth Rate of growth Metastasis General effects Tissue destruction Ability to cause disease

Which specific agents or factors are associated with the etiology of cancer? A) Dietary and genetic factors B) Hormonal and chemical agents C) Viruses D) All of the above

D) All of the above Rationale: Specific agents or factors associated with the etiology of cancer include viruses and bacteria, physical factors; sunlight, radiation, chronic irritation, chemical agents; tobacco, asbestos, genetic and familial factors, diet, hormones.

Diagnosis of cancer

Determine presence, extent of tumor Identify possible spread (metastasis) of disease or invasion of other body tissues Evaluate function of involved, uninvolved body systems, organs Obtain tissue, cells for analysis, including evaluation of tumor stage, grade

Alopecia

Discuss potential hair loss, regrowth with patient, family Explore potential impact of hair loss on self-image, interpersonal relationships, sexuality Prevent or minimize hair loss Prevent trauma to scalp Suggest ways to assist in coping with hair loss: Encourage patient to wear own clothes, retain social contacts Explain that hair growth usually begins again once therapy is completed

*Impaired Skin Integrity: Wet Desquamation

Do not disrupt any blisters that have formed Avoid frequent washing of area Report any blistering Use prescribed creams or ointments If area weeps, apply nonadhesive absorbent dressing If area is without drainage, use moisture-, vapor-permeable dressings such as hydrocolloids, hydro gels on noninfected areas (Swearingen, 2008) Consult with enterostomal therapist (ET), physician if eschar forms

cell kill and cell cycle

Each time a tumor is exposed to chemotherapy, a percentage of the tumor cells (20-99%, depending on the dosage) are destroyed. Repeated doses of chemotherapy are necessary over a prolonged period of time to achieve regression of the tumor. Actively proliferating cells within a tumor are the most sensitive to chemo nd nondividing cells that are capable of future proliferating are the least sensitive (dangerous) however, the nondividing must be destroyed to eradicate the tumor. The cells divide in a pattern/cycle: G1- RNA and protein synthesis occur S- DNA synthesis occurs G2- premitotic phase, DNA synthesis is complete, mitotic spindle forms Mitosis- cell division occurs G0- (occurs after G1) is a resting phase that cells might fall into temporarily- these are the dangerous ones that need to be destroyed since they have the potential for replicating.

Prophylactic surgery

involves removing nonvital tissues or organs that are at increased risk of developing cancer. (mastectomy, colectomy, oophorectomy). Factors to consider when discussing possible prophylactic surgery: -Family Hx and genetic disposition -Presence or absence of signs and symptoms -Potential risks and benefits -Ability to detect cancer at an early stage -Alternative options for managing increased risk -The pt.s' acceptance of the postop outcome

secondary prevention

involves screening and early detection activities that seek to identify early stage cancer in individuals who lack signs and symptoms suggestive of cancer the goal is to decrease cancer morbidity and mortality associated with advanced stages of cancer and complex treatment approaches.

Chemotherapy

involves the use of antineoplastic drugs in an attempt to destroy cancer cells by interfering with cellular functions, including replication and DNA repair. used primarily to treat systemic disease rather than localized lesions that are amenable to surgery or radiation. Cure, control or palliative-- goal must be realistic because they will determine the medications that are used and the aggressiveness if the treatment plan.

Carginogenesis

malignant transformation: 3 step process involving initiation, promotion, and progression.

Reconstructive surgery

may follow curative or radical surgery in an attempt to improve function or obtain a more desirable cosmetic effect. It may be performed in one operation or in stages.

Excisional biopsy

most frequently used for small, easily accessible tumors of the skin, breast, and upper and lower gastrointestinal and upper respiratory tracts. The removal of normal tissue beyond the tumor area decreases the probability that residual microscopic malignant cells may lead to a recurrence of the tumor.

benign

noncancerous

Graft versus Host Disease (GVHD)

occurs when the donor lymphocytes initiate an immune response against the recipient's tissues during the beginning of engraftment. Results in morbidity and mortality in 30%-50% of the allogeneic transplant population.

Incisional biopsy

performed if the tumor mass is too large to be removed. A wedge of the tumor is removed for analysis. The cells of the tissue wedge must be representative of the tumor mass so that the pathologist can provide an accurate diagnosis.

Needle biopsy

performed to sample suspicious masses that are easily and safely accessible, such as some masses in the breasts, thyroid, lung, liver, and kidney. Needle biopsies are most often performed on an outpatient basis. They are fast, relatively inexpensive, easy to perform, and usually require only local anesthesia.

apoptosis

programmed cell death/cell senescence

control

prolonged survival and containment of cancer cell growth

Tumor staging

provides a common language used by health care providers and scientists to accurately communicate about cancer in and across clinical settings and in research determines the size of the tumor, the existence of local invasion, lymph node involvement, and distant metastasis TNM (tumor, nodes, metastasis)

palliation

relief of symptoms associated with the disease and improvement of quality of life

promotion phase of carginogenesis

repeated exposure to carcinogens cause proliferation and expansion of initiated cells with increased expression or manifestations of abnormal genetic information, even after long latency periods (damage has already been done).

surgical treatment

surgical removal of the entire cancer remains the ideal and most frequently used method of treatment. diagnostic surgery or BIOPSY, is performed to obtain a tissue sample for histologic analysis of cells suspected to be malignant

progression phase of carginogenesis

the altered cells exhibit increasingly malignant behavior. They acquire the ability to stimulate angiogenesis, to invade adjacent tissues, and to metastasize.

Hematogenous Spread

the dissemination of malignant cells via the bloodstream- is directly related to the vascularity of the tumor. Few malignant cells can survive the turbulence of arterial circulation, insufficient oxygenation, or destruction by the body's immune system.

Angiogenesis

the growth of new blood vessels from the host tissue stimulated by the release of growth factors such as vascular endothelial growth factor (VEGF). Rapid formation of new blood vessels helps malignant cells obtain the necessary nutrients and oxygen... however, the vessels formed in this deregulated process are morphologically abnormal and function inefficiently.

Grading

the pathological classification of tumor cells; seek to define the type of tissue from which the tumor originated and the degree to which the tumor cells retain functional and histologic characteristics of the tissue of origin (differentiation). The grade corresponds with a numeric value ranging from I-IV.

Lymphatic Spread

the transport of tumor cells through the lymphatic circulation (most common mechanism of metastasis). Tumor emboli enter the lymph channels by way of interstitial fluid, which communicates with lymphatic fluid. Malignant cells also may penetrate lymphatic vessels by invasion (lodge in lymph nodes or pass between the lymphatic and venous circulations).

True or False: Malignant tumors spread by way of blood and lymph channels to other areas of the body?

True Rationale: Malignant tumors spread by way of blood and lymph channels to other areas of the body. Cells bear little resemblance to the normal cells of the tissue from which they arose.

Is the following statement true or false? The most common cause of bleeding in cancer patients is thrombocytopenia.

True Rationale: The most common cause of bleeding in cancer patients is thrombocytopenia.

Bone Marrow Transplantation (BMT)

Used for hematological cancers that effect marrow or solid tumors treated with chemotherapy dosage that ablates bone marrow Allogeneic HSCT- from a donor other than the patient (family member or unrelated donor from the National Bone Marrow Registry or Cord Blood Registry) Autologous- From the Pt. Syngeneic- From an identical twin

Venous occlusive disease

VOD= complication from high dose chemo given before BMT; s/e= fluid retention, increased liver size, elevated bili

Carcinogenic Agents and Factors

Viruses, bacteria - about 20% Physical factors: sunlight, radiation, chronic irritation Chemical agents: tobacco, asbestos Genetic, familial factors Diet Hormones

Metastasis

abnormal cells have invasive characteristics, infiltrate other tissues (spreading/growing of cancer throughout the body).

carcinogens

agents that initiate or promote cellular transformation (Example: tobacco) include chemicals, physical factors, and biologic agents.

Internal VS External Radiation

Internal- (BRACHYTHERAPY): delivers the dose of radiation to a localized area External (EBRT (external beam radiation therapy)): most commonly used form of radiation therapy. Through computerized software programs, they are able to shape an invisible beam of highly charged electrons to penetrate the body and target the tumor with pinpoint accuracy

Distant Metastasis (M)

MX- Distant metastasis cannot be assessed M0- No distant metastasis M1- Distant metastasis

Regional Lymph Nodes (N)

NX- Regional lymph nodes cannot be assessed N0- No regional lymph node metastasis N1, N2, N3- Increasing involvement of regional lymph nodes

Effects of Radiation Therapy

body tissues most affected are those that normally proliferate rapidly, such as the skin, epithelial lining of the GI tract and the bone marrow. Altered skin integrity is common and can include ALOPECIA (hair loss) associated with whole brain radiation, other skin conditions such as radiation dermatitis, erythema, and dry desquamation (flaking of skin) or moist desquamation (skin oozing serous fluids), ulceration. Hyperpigmentation may occur 2-4 weeks after the initiation of therapy. STOMATITIS- inflammation of the oral tissues decreased salvation XEROSTOMIA- dryness of the mouth change or loss in taste MUCOSITIS- inflammation of the lining of the GI tract (chest pain or dysphagia). anorexia, nausea, vomiting diarrhea anemia, leukopenia (decreased WBC) and THROMBOCYTOPENIA (decrease in platelets), bleeding

Malignant process

cancer is a disease process that begins when a cell is transformed by genetic mutations of the cellular DNA Genetic mutations result from inherited and/or acquired mutations that lead to abnormal cell behavior. The genetically altered cell forms a clone and begins to proliferate abnormally, evading normal intracellular and extracellular growth-regulating processes or signals as well as other defense mechanisms of the body. The cells acquire a variety of capabilities that allow them to invade surrounding tissue and gain access to lymph and blood vessels, which carry the cells to other areas of the body.

initiation phase of carginogenesis

carcinogens cause mutations in the cellular deoxyribonucleic acid (DNA). Normally these alterations are revered by DNA repair mechanisms or the changes initiate apoptosis.

cure

complete eradication of malignant disease

primary prevention

concerned with reducing cancer risk in healthy people through health promotion and risk reduction strategies; avoid known carcinogens Lifestyle, dietary changes to reduce cancer risk Public, patient education

Malignant cancer cells

demonstrate uncontrolled growth that does not follow physiologic demand

Nursing Care of the Patient Undergoing Radiation Therapy

Patient, family education Restrictions, precautions (bed rest, log-rolled positioning/turning, catheter, low-residual diets, anti-diarrheal medications...) Skin care Oral care Protection of care providers (time, distance, and shielding to minimize exposure of personnel to radiation)

Septic Shock

Septicemia, septic shock life-threatening complications that must be prevented or detected, treated promptly Patients who are neutropenic and/or who have hematologic malignancies are at greatest risk Signs, symptoms include altered mental status, either subnormal or elevated temperature, cool and clammy skin, decreased urine output, hypotension, tachycardia, other dysrhythmias, electrolyte imbalances, tachypnea, abnormal arterial blood gas values

*Oncologic Emergencies

Superior vena cave syndrome- blockage of circulation, causes edema above neck Spinal cord compression Pericardial effusion, cardiac tamponade-fluid around heart Disseminated intravascular coagulation (DIC) Syndrome of inappropriate secretion of antidiuretic hormone- excess water Tumor lysis syndrome- few days after chemo

Bleeding and Hemorrhage

Thrombocytopenia (decrease in circulating platelet count): most common cause of bleeding in patients with cancer, usually defined as platelet count of less than 100,000/mm3 (0.1 × 1012/L) Plan of nursing care addresses nursing assessment parameters, interventions for patients at risk for bleeding

TNM (tumor, nodes, metastasis) Classification System

T- the extent of the PRIMARY TUMOR N- The absence or presence and extent of regional lymph NODE metastasis M- The absence or presence of distant METASTASIS

Primary Tumor (T)

TX- primary tumor cannot be assessed T0- No evidence of primary tumor Tis- Carcinoma in situ T1, T2, T3, T4- Increasing size and/or local extent of the primary tumor

Chemotherapy Toxicity

Gastrointestinal- nausea, vomiting Hematopoietic- MYELOSUPPRESSION (depression of bone marrow function), leukopenia, neutropenia, anemia, etc.. Renal-damage to kidneys, impair water secretion, inappropriate secretion of antidiuretic hormone (fluid retention), decreased renal perfusion, (monitor BUN + creatinine) Cardiopulmonary-pulmonary edema, capillary leak syndrome Reproductive- sterility (possible), issues with ovulation, Neurologic- chemo-induced neurotoxicity, affect CNS, PNS, and/or cranial nerves, tingling, prickling or numbness of extremities; burning or freezing pain; sharp, stabbing, or electric shock-like pain; and extreme sensitivity to touch Cognitive-difficulty remembering dates, multitasking, managing numbers and finances, organization, face or object recognition, inability to follow directions, feeling easily distracted, and motor and behavioral changes Fatigue- affects quality of life

Grade I versus Grade IV

Grade I tumors, also known as well-differentiated tumors, closely resemble the tissue or origin in structure and in function. Tumors that do not closely resemble the tissue of origin in structure or function are described as poorly differentiated or undifferentiated and are assigned a grade of IV. Grade IV tend to be more aggressive, less responsive to treatment, and associated with a poorer prognosis as compared to well-differentiated, grade I tumors.