Cancer

-The range of possible treatment goals may include 1)cancer prevention, 2)complete eradication of malignant disease (cure), 3)prolonged survival and prevention of progression (control), 4)relief of symptoms associated with the disease (palliation).

-A variety of approaches, including surgery, radiation therapy, chemotherapy, targeted therapy and immunotherapy, may be used at various times throughout treatment. -Understanding the principles of each treatment modality and how they interrelate is important in understanding the rationale and goals of treatment.

-In patients with an absolute neutrophil count (ANC) below 500/µL, prophylactic antibiotics should be considered, and in the presence of fever, empiric antibiotics must be started promptly (Ferri, 2016d).

-Benign and malignant growths are classified and named by tissue of origin. -Benign and malignant cells differ in many cellular growth characteristics, including the method and rate of growth, ability to metastasize or spread, general effects, destruction of tissue, and ability to cause death -Despite their individual differences, all cancer cells share some common cellular characteristics in relation to the cell membrane, 1)special proteins, 2)the nuclei, 3)chromosomal abnormalities, 4)and the rate of mitosis and growth

Nursing Alert Indications of extravasation during administration of vesicant agents include: -Absence of blood return from the IV catheter -Resistance to flow of IV fluid -Leaking around the insertion site -Swelling, pain, burning, or redness or blistering at the site, or if using a CVAD, pain in the upper arm, upper back, chest, neck, or jaw -For some drugs (anthracyclines such as doxorubicin), signs and symptoms of extravasation may continue for weeks after drug administration (Kreidieh et al., 2016).

-If any one of the above signs is present, extravasation should be suspected: -The medication administration should be stopped immediately. -The nurse should attempt to aspirate any residual drug from the IV line. -If an antidote is indicated, the nurse should administer it immediately (as ordered). -Selection of the neutralizing solution or antidote depends on the extravasated agent. *Dexrazoxane is approved in the setting of anthracycline extravasation with efficacy rates as high as 98% in preventing tissue damage. -Dexrazoxane is administered as a 1- to 2-hour IV infusion for 3 consecutive days. Treatment with dexrazoxane should be initiated within 6 hours of extravasation for best results

-Carcinogenesis-the process in which healthy cells become malignant, is a multi-step process involving both environmental exposure to cancer-causing agents (carcinogens) and random errors in replication of DNA that result in genetic mutations over time. -The end result of these mutations is uncontrolled proliferation of abnormal cells. Carcinogensis- is the result of both genetic and epigenetic changes. The term epigenetics refers to heritable, reversible changes in gene expression that do not involve changes to the underlying DNA sequence.

-Nadir is the lowest ANC after myelosuppressive chemotherapy or radiation therapy -Therapies that suppress bone marrow function are called myelosuppressive. -Therapies that severely suppress bone marrow function are called myeloablative. - The nadir is reached, on average, 7 to 10 days following chemotherapy treatment and takes an additional 7 to 14 days to recover. -The patient is at increased risk for infection throughout the duration of neutropenia.

H. pylori can lead to cancer in the lower part of the stomach and is also associated with some types of stomach lymphoma.Bacteria -A few bacteria are associated with the development of cancer. An example is Helicobacter pylori (H pylori) which is linked with gastric ulcers. -H. pylori can lead to cancer in the lower part of the stomach and is also associated with some types of stomach lymphoma. -

-Neutropenia, an abnormally low ANC, is associated with an increased risk for infection -The risk for infection rises as the ANC decreases and persists. -An ANC less than 500 cells/mm3 reflects a severe risk of infection. -Nadir is the lowest ANC after myelosuppressive chemotherapy or radiation therapy. -Therapies that suppress bone marrow function are called myelosuppressive. T -herapies that severely suppress bone marrow function are called myeloablative. -The nadir is reached, on average, 7 to 10 days following chemotherapy treatment and takes an additional 7 to 14 days to recover. -The patient is at increased risk for infection throughout the duration of neutropenia.

-In radiation therapy, ionizing radiation is used to interrupt cellular growth. -More than half of patients with cancer receive a form of radiation therapy at some point during treatment. -Radiation may be used to cure the cancer, as in head and neck, prostate, lung, and bladder cancers. -Radiation therapy may also be used to control malignant disease when a tumor cannot be removed surgically or when local nodal metastasis is present, or it can be used prophylactically to prevent leukemic infiltration to the brain (Iwamoto, Haas, & Gosselin, 2012).

-Palliative radiation therapy is used to relieve the symptoms of metastatic disease, especially when the cancer has spread to brain, bone, or soft tissue, or to treat oncologic emergencies, such as superior vena cava syndrome (SVCS) or spinal cord compression. -Two types of ionizing radiation—electromagnetic rays (x-rays and gamma rays) and particles (electrons [beta particles], protons, neutrons, and alpha particles)—can lead to tissue disruption. -Radiation disrupts malignant cell proliferation through the alteration in DNA structure. Ionizing radiation breaks the strands of the DNA helix, leading to cell death. -Ionizing radiation can also ionize constituents of body fluids, especially water, leading to the formation of free radicals and irreversible DNA damage. -If the DNA is incapable of repair, the cell may die immediately, or it may initiate apoptosis

-Cancer-not a single disease with a single cause; rather, it is a highly heterogeneous group of diseases with different causes, manifestations, treatments, and prognoses. -Metastasis- Tumors also have the capacity to invade and spread from their original site to other organs in the body. -The two most common mechanisms of metastasis are via lymphatic channels or blood vessels -The most common sites of metastasis include the bones, lungs, liver, and central nervous system (CNS). -The site of metastasis is influenced by 1) the availability of a blood supply, 2) cell receptors and genes that may direct the malignant cell to travel to specific sites, 3)and the presence of growth factors essential for metastatic growth that may be elicited only in selected organs.

-Staging-determines the size of the tumor and the extent of disease. Several systems exist for classifying the disease stage -Grading refers to the classification of the tumor cells.thrombocytopenia (a decrease in platelets) -thrombocytopenia (a decrease in platelets) -Stomatis- inflammation of the mucous of the mouth Neutropenia- the presence of abnormally few neutrophils in the blood, leading to increased susceptibility to infection. It is an undesirable side effect of some cancer treatments.

-body tissues that undergo frequent cell division are most sensitive to radiation therapy. -These radiosensitive tissues include bone marrow, lymphatic tissue, epithelium of the GI tract, hair cells, and gonads. -Slower-growing tissues and tissues at rest are relatively radioresistant (less sensitive to the effects of radiation). -Such tissues include muscle, cartilage, and connective tissues. -A radiosensitive tumor is one that can be destroyed by a dose of radiation that still allows for cell regeneration in the normal tissue. -- -Tumors that are well oxygenated also appear to be more sensitive to radiation -In theory, therefore, radiation therapy may be enhanced if more oxygen can be delivered to tumors

-if the radiation is delivered when most tumor cells are cycling through the cell cycle, the number of cancer cells destroyed (cell kill) is maximal. -Certain chemicals, including chemotherapy and some targeted agents (e.g., EGFR inhibitors) act as radiosensitizers and sensitize more hypoxic (oxygen-poor) tumors to the effects of radiation therapy (Iwamoto et al., 2012). -Radiation is delivered to tumor sites by external or internal methods.

ASSESSING AND MANAGING STOMATITIS

ASSESSING AND MANAGING STOMATITIS

ASSESSING AND MANAGING STOMATITIS -Nurses must perform routine oral assessments in patients at risk for developing stomatitis and in patients with established stomatitis. -Standardized oral assessment guides exist to facilitate objective descriptions of the oral mucosa -The assessment should include the color and moisture of the lips and oral mucosa; presence of ulcerations; presence of edema of the lips, buccal mucosa, or tongue; and quantity and quality of saliva. -The nurse also assesses the level of pain that the patient experiences secondary to stomatitis, alterations in the patient's ability to talk or sleep, and nutritional intake

ASSESSING AND MANAGING STOMATITIS -Although multiple studies on stomatitis have been published, the optimal prevention and treatment approaches have not been identified. -Future studies will focus on addressing the cascade of inflammatory events and release of chemical substances that leads to the cellular and tissue destruction underlying stomatitis. -Routine, good oral hygiene, including brushing, flossing, and rinsing, is necessary to minimize the risk of oral complications associated with cancer therapies. -

ASSESSING AND MANAGING STOMATITIS -Mucositis is a common side effect of radiation and some types of chemotherapy that may lead to inflammation and ulceration of any portion of the GI tract from the oral cavity throughout the alimentary canal -One form of mucositis, stomatitis, is an inflammatory response of the oral tissues that is characterized by mild redness (erythema) and edema or, if severe, by painful ulcerations, bleeding, and secondary infection. -Stomatitis commonly develops 5 to 14 days after patients receive myelosuppressive chemotherapeutic agents and often coincides with the WBC nadir

ASSESSING AND MANAGING STOMATITIS -As many as 40% of patients receiving standard-dose chemotherapy experience some degree of stomatitis during treatment, and up to 100% of patients receiving high-dose chemotherapy or combination therapy with radiation and chemotherapy for treatment of head and neck cancers may experience stomatitis -As a result of normal everyday wear and tear, the epithelial cells that line the oral cavity undergo rapid turnover and slough off routinely.

ASSESSING AND MANAGING STOMATITIS -Soft-bristled toothbrushes and nonabrasive toothpaste prevent or reduce trauma to the oral mucosa. -Oral swabs with sponge-like applicators may be used in place of a toothbrush for painful oral tissues. -Flossing may be performed unless it causes pain or bleeding. -Oral rinses with saline solution or tap water after meals and at bedtime may be necessary for patients who cannot tolerate tooth brushing. -Products that irritate oral tissues or impair healing, such as alcohol-based mouth rinses, are avoided.

ASSESSING AND MANAGING STOMATITIS -Foods that are difficult to chew or that are hot or spicy are avoided to minimize further trauma. -The patient's lips are lubricated to keep them from becoming dry and cracked. -Topical anti-inflammatory and anesthetic agents may be prescribed to promote healing and minimize discomfort. -Products that coat or protect oral mucosa are used to promote comfort and prevent further trauma. -Patients who experience severe pain and discomfort with stomatitis require systemic analgesics.

ASSESSING AND MANAGING STOMATITIS -Until recently, stomatitis was thought to occur because chemotherapy and radiation interfered with this process. -Mucositis is now understood as a complex process involving inflammation, tissue damage, cell death, cytokine release, and microbes in the oral cavity -Poor oral hygiene, existing dental disease, use of other medications that dry mucous membranes, advanced age, smoking, previous cancer treatment, diminished kidney function, and impaired nutritional status all contribute to morbidity associated with stomatitis. -Radiation-induced xerostomia (dry mouth) associated with decreased function of the salivary glands may contribute to stomatitis in patients who have received radiation to the head and neck.

ASSESSING AND MANAGING STOMATITIS -Myelosuppression (bone marrow depression), resulting from underlying disease or its treatment, predisposes the patient to oral bleeding and infection. -Severe pain associated with ulcerated oral tissues can significantly interfere with nutritional intake, speech, and a willingness to maintain oral hygiene. -Severe stomatitis may cause or prolong hospitalizations. -In addition, stomatitis may lead to interruptions in chemotherapy and radiation administration or decreases in the intended dosing until the inflammation subsides. -Further, it may significantly reduce the patient's quality of life.

ASSESSING AND MANAGING STOMATITIS -Adequate fluid and food intake is encouraged. -In some instances, parenteral hydration and nutrition are necessary. -Topical or systemic antifungal and antibiotic medications are prescribed to treat local or systemic infections. -Cryotherapy (sucking on ice chips) has demonstrated a reduction in pain incidence and severity in patients being treated with drugs with a short half-life (e.g., bolus 5-fluorouracil, melphalan) (Eilers et al., 2014). -Low-level laser therapy has also demonstrated a reduction in prevalence, severity, pain, and duration of mucositis

ASSESSING AND MANAGING STOMATITIS -Palifermin, a synthetic form of human keratinocyte growth factor, is an IV medication approved in 2005 by the FDA for treatment of mucositis in patients with hematologic malignancies who are undergoing high-dose chemotherapy or total body radiation prior to HCST. -Palifermin appears to promote more rapid replacement of cells in the mouth and GI tract, decreasing the incidence and duration of severe mucositis. -It has not yet been tested in other patients with cancer. -Careful timing of administration and monitoring are essential for maximum effectiveness and to detect adverse effects

Radiation toxicity -Bone marrow cells proliferate rapidly, and if sites containing bone marrow (e.g., the iliac crest, sternum) are included in the radiation field, anemia, leukopenia (decreased WBCs), and thrombocytopenia (a decrease in platelets) may result. -increased risk for infection and bleeding until blood cell counts return to normal. -Chronic anemia may occur commonly due to the cumulative effects of radiation and may be evidenced by shortness of breath, dizziness, fatigue, decreased oxygen saturation, and decreased activity tolerance. -

Acute side effects -can occur within hours to days of receiving the first treatment. -Bone marrow suppression, gonadal toxicity, skin changes, salivary changes, and GI side effects, such as nausea, may occur acutely. -Late effects from radiation are seen months to years after therapy even in the absence of acute symptoms. -These effects include changes to the pituitary and thyroid glands, lungs, bones, breasts, cartilage, and pancreas (Iwamoto et al., 2012).

Providing Post-transplantation care -Cataracts may also develop after total body irradiation. -Psychosocial assessments by nursing staff must be ongoing. -In addition to the stressors affecting patients at each phase of the transplantation experience, marrow donors and family members also have psychosocial needs that must be addressed.

Based on the assessment data, potential complications include the following: -Infection and sepsis -Hemorrhage -SVCS -Spinal cord compression -Hypercalcemia -Pericardial effusion -Disseminated intravascular coagulation (DIC) -Syndrome of inappropriate secretion of -antidiuretic hormone (SIADH) -Tumor lysis syndrome

CARING FOR PATIENTS WITH NAUSEA AND VOMITING -The prevention of chemotherapy-induced nausea and vomiting is a priority (see earlier discussion). - For nausea and vomiting unrelated to chemotherapy, medications including serotonin receptor antagonists (e.g., ondansetron), dopamine receptor antagonists (e.g., metoclopramide), phenothiazines (e.g., prochlorperazine), corticosteroids (e.g., dexamethasone), and cannabinoids (e.g., dronabinol) can be used.

CARING FOR PATIENTS WITH NAUSEA AND VOMITING -Antiemetics should be administered around the clock with breakthrough doses as needed. -Nonpharmacologic interventions that have proven to be effective in decreasing nausea include relaxation, guided imagery, acupressure, acupuncture, deep breathing, and eliminating odors. -Patients should be instructed to avoid reclining within the first 30 minutes after eating. -Dietary interventions include eating small, frequent meals and eating bland, chilled foods.

CARING FOR PATIENTS WITH NAUSEA AND VOMITING -Nausea is an unpleasant sensation experienced in the back of the throat, epigastrium, or stomach that may result in vomiting. -Nausea is one of the most feared side effects of cancer treatment. -The potential causes of nausea are numerous, and nurses should not assume that nausea is due to chemotherapy; all potential causes must be considered. -Causes of nausea include primary or metastatic tumor involving the CNS; gastroparesis (slowed gastric emptying); obstruction in the GI tract; infection; hypercalcemia; kidney or liver dysfunction; hyponatremia; and side effects of medications including chemotherapy, morphine, and antibiotics. -Risk factors for treatment-induced nausea include younger age, female sex, and a history of treatment-induced nausea and vomiting.

CARING FOR PATIENTS WITH NAUSEA AND VOMITING -Nausea is a subjective phenomenon analogous to pain. -Nausea is best assessed by eliciting the patient's self-report. -The following components should be assessed: timing of nausea in relation to treatment, perceived meaning of nausea to the patient, onset, frequency, associated symptoms, precipitating and alleviating factors, and previous experiences with nausea. -Physical assessment should include signs of sweating, tachycardia, dizziness, pallor, excessive salivation, weakness, gastric distention, abdominal tenderness, and evaluation of bowel sounds. -Laboratory values including electrolytes and kidney function should be monitored.

Hematopoietic system -Specific guidelines are now available to improve the safety of ESA administration, -including holding ESAs for Hgb levels greater than 10 mg/dL, -assessing the hemoglobin (Hgb) and hematocrit (Hct) prior to each ESA dose, and discontinuing ESA use in patients who do not achieve a significant benefit within the first 8 weeks of administration.

CHEMO; REPRODUCTION SYSTEM -Ovarian and testicular function can be affected by chemotherapeutic agents, resulting in possible sterility. -Abnormal ovulation, early menopause, or permanent sterility may occur. -In men, temporary or permanent azoospermia (absence of spermatozoa) may develop -Reproductive cells may be damaged during treatment, resulting in chromosomal abnormalities in offspring.

EXTRAVASATION -A plastic surgery consult should be considered within the first 24 hours -Recommendations and guidelines for managing vesicant extravasation have been issued by individual medication manufacturers, pharmacies, and the ONS, and they differ for each medication.

CHEMOTHERAPY [GI SYSTEM] -Chemotherapy-induced nausea and vomiting (CINV) is a common and feared side effect of chemotherapy and may persist for as long as 24 to 48 hours after its administration -Delayed nausea and vomiting is commonly seen with cisplatin, carboplatin, cyclophosphamide, and doxorubicin -Anticipatory nausea may be experienced after the first cycle and is caused by classical conditioning; nausea is triggered by taste, odors, sights, thoughts, or anxiety related to a poor initial experience with CINV

CHEMOTHERAPY [GI SYSTEM] -The primary risk factor for CINV is the emetogenic potential of the agents being used (how likely the agents are to cause nausea and vomiting) -. Patient-specific risk factors include a history of CINV, female sex, under 50 years of age, and history of motion sickness. -A history of heavy alcohol use is associated with decreased risk for CINV

CHEMOTHERAPY [GI SYSTEM] -The goal of antiemetics is to prevent CINV. -Antiemetic regimens are tailored based on the emetogenicity of the regimen -For patients with a high risk of nausea and vomiting who are receiving regimens, a combination of a 5-HT3 antagonist, an NK1 antagonist, and a corticosteroid are given prior to initiation of treatment

CONTINUING CARE -Referral for home care is often indicated for patients with cancer. - The responsibilities of the home care nurse include assessing the home environment, suggesting modifications in the home or in care to help the patient and family address the patient's physical needs, providing physical care, and assessing the psychological and emotional impact of the illness on the patient and family. -Assessing changes in the patient's physical status and reporting relevant changes to the provider help ensure that appropriate and timely modifications in therapy are made. -The home care nurse also assesses the adequacy of pain management and the effectiveness of other strategies to prevent or manage the side effects of treatment modalities.

CONTINUING CARE -It is necessary to assess the patient's and family's understanding of the treatment plan and management strategies and to reinforce previous teaching. -The nurse often facilitates coordination of patient care by maintaining close communication with all involved health care providers. -The nurse may make referrals and coordinate available community resources (e.g., local office of the American Cancer Society, home aides, church groups, parish nurses, support groups) to assist patients and caregivers.

Cachexia. -common in patients with cancer with prevalence ranging from 40% at cancer diagnosis to 70% to 80% in advanced phases of the disease. - It is a multifactorial syndrome marked by loss of skeletal muscle mass without loss of fat mass that cannot be entirely reversed by nutritional support alone (Penet & Bhujwalla, 2015). -Cachexia is defined as a weight loss of 10% body weight or more within 6 months, a BMI below 20, and any weight loss greater than 2% (Penet & Bhujwalla, 2015; Polovich et al., 2014).

Cachexia. -characterized by negative protein and energy balance as a result of decreased food intake and abnormal metabolism -Cachexia often leads to a decline in functional status, quality of life, and decreased tolerance to treatment. -Progressive cachexia suggests a poor prognosis and accounts for 20% of all cancer deaths. -Treatment includes nutritional support and counseling and treatment of the underlying malignancy.

Characteristics of cancer cells include: -Pleomorphism: Cells vary in size and shape -Polymorphism: Nucleus is enlarged and variable in shape Chromosomal mutations including translocations, deletions, amplification, and aneuploidy (abnormal number of chromosomes) -Production of surface enzymes that aid in invasion and metastasis -Loss of antigens that label the cell as "self" -Production of new tumor-associated antigens that label the cell as "nonself" -Increased rate of anaerobic metabolism

Characteristics of cancer cells include: (continued) -Loss of contact inhibition, which normally halts cell division once cells are in contact with one another -Defect in cell recognition and adhesion (cancer cells do not recognize and adhere to each other as normal cells do) -Loss of control of proliferation -Increased mitotic index: Tumors have a larger number of cells that are in mitosis -Abnormal lifespan: Cancer cells tend to live longer than do normal cells

Chemotherapy -antineoplastic agents are used in an attempt to destroy tumor cells by interfering with cellular functions, including replication -used primarily to treat systemic disease rather than localized lesions that are amenable to surgery or radiation -combined with surgery, radiation therapy, or both to reduce tumor size preoperatively (neoadjuvant), to destroy any remaining tumor cells postoperatively (adjuvant), for conditioning therapy prior to stem cell transplant, or to treat hematologic malignancies, such as lymphoma and leukemia -The goals of chemotherapy (cure, control, palliation) define the medications to be used and the aggressiveness of the treatment plan. -Chemotherapy may also be delivered in the setting of a clinical trial (see Box 6-4).

Chemotherapy -Each time a tumor is exposed to a chemotherapeutic agent, a percentage of tumor cells (20% to 99%, depending on dosage) are destroyed -Eradication of 100% of the tumor is almost impossible. -Instead, the goal of treatment is eradication of enough of the tumor so that the remaining tumor cells can be destroyed by the body's immune system. -The goal of combination chemotherapy is to overcome drug resistance and take advantage of the synergistic effects of some drugs while minimizing toxicity -tumors are heterogeneous so agents with different mechanisms of action are used in combination to increase the number of cells killed; -combination approaches also reduce the risk of drug resistance. -Considerations for combination chemotherapy include the use of drugs with different mechanisms of action and different side effect profile

Classification of chemotherapeutic agents -may be classified by their relationship to the cell cycle. -Certain chemotherapeutic agents that are specific to certain phases of the cell cycle are termed cell cycle-specific agents. -These agents destroy cells that are actively reproducing by means of the cell cycle; most affect cells in the S phase by interfering with DNA and RNA synthesis. -vinca or plant alkaloids, are specific to the M phase, where they halt mitotic spindle formation. -Chemotherapeutic agents that act independently of the cell cycle phases are termed cell cycle-nonspecific agents. -These agents usually have a prolonged effect on cells, leading to cellular damage or death.

Classification of chemotherapeutic agents -Chemotherapeutic agents are also classified by chemical group, each with a different mechanism of action. -These include the alkylating agents, nitrosoureas, antimetabolites, antitumor antibiotics, plant alkaloids, hormonal agents, and miscellaneous agents. -The classification, mechanism of action, common medications, and common side effects of selected antineoplastic agents are listed in Table 6-3.

Administration of Chemo agents -variety of routes including topical, oral, IV, intramuscular, subcutaneous, arterial, intracavitary, and intrathecal routes -Intrathecal chemotherapy is the administration of medication into the cerebrospinal fluid. -accomplished through a lumbar puncture or through the placement of an intraventricular catheter with the tip lying in the fourth ventricle of the brain. -used to treat or prevent CNS metastasis -depends on the type of agent; the required dose; and the type, location, and extent of tumor being treated.

Dosage -Dosage of antineoplastic agents is based primarily on the patient's total body surface area, previous response to chemotherapy or radiation therapy, function of major organ systems, and PS. -Nursing Alert Because of the high potential for error related to chemotherapy dosing, the standard expectation is that two nurses verify the chemotherapy doses to ensure accuracy. The Mosteller Equation for calculation of body surface area is the most commonly used formula in the United States:

EXTRAVASATIN -Examples of neutralizing solutions include sodium thiosulfate, hyaluronidase, and sodium bicarbonate -Hyaluronidase = enzyme administered as a subcutaneous injection into the extravasation site the degrades hyaluronic acid in tissues and promotes diffusion of the extravasated agent. -recommended for vinca-alkaloids, etoposide and taxanes extravasation with low levels of evidence supporting its use. -Sodium thiosulfate is also administered via subcutaneous injection for nitrogen mustard extravasations [It is essential for nurses to keep up with the research findings related to extravasation and to apply the evidence to clinical practice.]

EXTRAVASATIN -The involved extremity should be elevated for the first 48 hours -ice is applied to the site (unless the extravasated vesicant is a vinca-alkaloid in which case warm compresses are used) (four times a day for 20 minutes for the first 48 hours), and the patient is educated to avoid further trauma to the site (including heat, constrictive clothing, sunlight) and to report changes in the skin integrity and appearance of the extravasation site to the provider immediately.

Nursing Alert -Prior to administration of any anticancer agent, the nurse must be aware of a drug's vesicant potential. -If frequent administration of antineoplastic vesicants is anticipated in a patient with poor veins, or if a vesicant agent requires administration over more than 1 hour, a central venous access device (CVAD) must be inserted to promote safety during medication administration. -Complications associated with CVAD use include infection and thrombosis. -Educating the patient about all risks associated with vesicant chemotherapy administration is critical.

EXTRAVASATION -Irritants are drugs that can cause pain or irritation at the extravasation site and burning sensation during administration but do not cause tissue damage. -Examples of irritants include bendamustine or carboplatin -Exfoliants are drugs that can cause inflammation and peeling or blistering of the skin without tissue necrosis. -Examples of exfoliants include Cisplatin, Docetaxel, Liposomal Doxorubicin, Mitoxantrone, Oxaliplatin, and Paclitaxe

HYPERSENSITY RESPONSE Response to HSRs includes: -stopping the infusion as soon as symptoms are observed; monitoring vital signs; maintaining a patent airway; administering oxygen as needed; maintaining a patent IV with running normal saline; administering emergency medications such as antihistamines, epinephrine, bronchodilators, and corticosteroids as ordered; and providing emotional support to the patient. -In mild reactions, reinitiation of the infusion at a slower rate may be considered. -For patients with more severe reactions, additional considerations are required for retreatment, including premedication with steroids and antihistamines (H1 and H2blockers) and, in some cases, desensitization protocols

EXTRAVASATION -Special care must be taken whenever IV vesicant agents are administered. -Vesicants are agents that, if deposited into the subcutaneous tissue (extravasation), cause tissue ulceration and necrosis as well as damage to underlying tendons, nerves, and blood vessels. -pH of many antineoplastic drugs is responsible for the severe inflammatory reaction as well as the ability of some of these drugs (e.g., anthracyclines) to bind to tissue DNA. -Sloughing and ulceration of the tissue may be so severe that skin grafting may be necessary. -Some examples of medications classified as vesicants include actinomycin D, dacarbazine, doxorubicin (Adriamycin), epirubicin, nitrogen mustard, mitomycin, vinblastine, vincristine, vinorelbine

GERONTOLOGIC CONSIDERATIONS -Treatment decisions should not be based on age alone; a thorough consideration of the patient's performance status and comorbidities is essential in decision making -Potential chemotherapy-related toxicities, such as renal impairment, myelosuppression, fatigue, and cardiomyopathy, may increase as a result of declining organ function and diminished physiologic reserves. -The recovery of normal tissues after radiation therapy may be delayed, and older patients may experience more severe adverse effects, such as mucositis, nausea and vomiting, and myelosuppression. -Because of decreased tissue-healing capacity and declining pulmonary and cardiovascular functioning, older patients are slower to recover from surgery. -Elderly patients are also at increased risk for complications such as atelectasis, pneumonia, and wound infections.

GERONTOLOGIC CONSIDERATIONS -Access to cancer care for elderly patients may be limited by discriminatory or fatalistic attitudes of health care providers, caregivers, and patients themselves. -Issues such as the gradual loss of supportive resources, declining health or loss of a spouse, and unavailability of relatives or friends may result in limited access to care and unmet needs for assistance with activities of daily living. -In addition, the economic impact of health care may be difficult for those living on fixed incomes.

MONITORING AND MANAGING INFECTION AND SEPSIS -A differential WBC count identifies the relative numbers of WBCs and permits tabulation of the absolute neutrophil count (ANC). -The ANC includes the number of polymorphonuclear neutrophils (mature neutrophils, reported as "polys," PMNs, or "segs") and immature forms of neutrophils (reported as bands, metamyelocytes, and "stabs"). -The ANC is calculated by the following formula: Total WBC × [%segs + %bands]

GERONTOLOGIC CONSIDERATIONS -More than half of all cancers occur in people older than 65 years of age, and 70% of all cancer deaths with prostate, bladder, colon, uterine, pancreatic, gastric, rectal and lung carcinomas accounting for the majority of cases -These changes include decreased skin elasticity; decreased skeletal mass, structure, and strength; decreased organ function and structure; impaired immune system mechanisms; alterations in neurologic and sensory functions; and altered drug absorption, distribution, metabolism, and elimination. -These changes ultimately influence the ability of elderly patients to tolerate cancer treatment. -In addition, many elderly patients have other chronic diseases and associated treatments that may limit tolerance to cancer treatments. --Polypharmacy is common in the elderly and the growing number of drug-drug interactions with newer anti-cancer therapies must be considered carefully

GERONTOLOGIC CONSIDERATIONS -Nurses must be aware of the special needs of the aging population. - Nurses carefully monitor elderly patients receiving cancer treatments for signs and symptoms of adverse effects. -In addition, elderly patients are instructed to report all symptoms to their provider. -It is not uncommon for elderly patients to delay reporting symptoms, attributing them to "old age." - Many elderly people do not want to report illness for fear of losing their independence or financial security.

GERONTOLOGIC CONSIDERATIONS -Sensory losses (e.g., hearing and visual losses) and memory deficits are considered when planning patient education because they may affect the patient's ability to process and retain information. -In such cases, the nurse acts as a patient advocate, encouraging independence and identifying resources, such as home care, for support when indicated. -Often elderly patients see a number of different doctors and subspecialists; coordination of care becomes critical (Suhag et al., 2015).

Staging -TNM system is used for many solid tumor types -T= event of primary tumor -N= lymph node involvement -M= extent of metastasis - other staging systems not well described by TNM = CNS cancers, hematologic cancers and Malignant melanoma

Grading - seek to define the type of tissue from which the tumor originated and the degree to which the tumor cells retain the functional ad histological characteristics of the tissue of origin -samples obtained through cytology(exam through tissue scraping - numeric value ranging I to IV -Grade 1 =well-differentiated tumors , closely resemble the tissue of origin in structure or function. -tumors that clearly do not clearly resemble the tissue of origin in structure or function = poorly differentiated or undifferentiated and are assigned grade IV (more aggressive and ;less responsive to txt than well-differentiated tumors. GX- grade cannot be assessed G1- well differentiated G2- moderately differentiated G3- Poorly differentiated G4-Undifferentiated

Protecting Caregivers -Chemotherapy agents are hazardous -potential for carcinogenicity, genotoxicity, teratogenicity, reproductive toxicity, and organ toxicity -Nurses may be exposed to low doses of the agents by direct contact, inhalation, or ingestion -Nurses must receive education on safe handling measures to minimize risks of exposure. -Exposure is often accidental and can happen during preparation, transport, administration, waste disposal, and spills -urinalysis -chemotherapeutic agents are associated with secondary formation of cancers and chromosomal abnormalities. -nausea, rashes, alopecia, and hearing loss have been reported in health care personnel who have handled chemotherapeutic agents -

HOSPICE -comprehensive multidisciplinary program that focuses on quality of life, palliation of symptoms, and provision of psychosocial and spiritual support for patients and families when cure and control of the disease are no longer possible. -the focus of care is on the family, not just the patient. -free-standing, hospital-based, and community- or home-based settings. -It is essential that home care and hospice nurses possess advanced skills in communication, assessing and managing pain, nutrition, dyspnea, bowel dysfunction, and skin impairments. -acilitate clear communication among family members and health care providers. -Hospice nurses are actively involved in bereavement counseling. -In many instances, family support for survivors continues for approximately 1 year.

Infusion related events -Assess for infusion reactions, hypersensitivity, and extravasation. Specific assessments vary based on the medication being administered -iNFUSION REACTIONS: -occur during or shortly after drug infusion are described as infusion reactions -may be allergic or nonallergic in nature. -anticipated when administering drugs such as monoclonal antibodies -Most infusion reactions are mild (e.g., chills) and, if recognized and treated promptly, should resolve. -initial management is interruption of the infusion and symptom management with antihistamines, antiemetics, steroids, or anxiolytics. In most cases, the infusion can be reinitiated and completed at a slower rate with careful monitoring

HYPERSENSITY -5% to 15% of patients receiving chemotherapy and biotherapy agents experience hypersensitivity reactions (HSRs) -risk of hypersensitivity varies based on the type of agent being administered. -Platinum- and taxane-containing agents have the most frequent incidence of HSRs -Prompt recognition of the symptoms of HSRs and quick intervention are critical roles -common symptoms observed in patients experiencing HSRs range from: flushing, rash (urticarial), nausea, vomiting, flushing, back pain, shortness of breath, and anxiety or sense of impending doom to bronchospasm and hemodynamic collapse

Helping Patients Cope with Alopecia -Hair loss usually begins 2 to 3 weeks after the initiation of treatment; regrowth begins within 8 weeks after the last treatment and may take up to 6 months for complete regrowth. -Some patients who undergo radiation to the head may sustain permanent hair loss. -Many health care providers view hair loss as a minor problem when compared with the potentially life-threatening consequences of cancer. -However, for many patients, hair loss is a major assault on body image, resulting in depression, anxiety, anger, rejection, and isolation. -To patients and families, hair loss can serve as a constant reminder of the challenges cancer places on coping abilities, interpersonal relationships, and sexuality.

Helping Patients Cope with Alopecia -Scalp cooling or scalp hypothermia has been studied with mixed results. -It is not recommended for patients with hematologic malignancies and should be used in the context of clinical trials in patients with solid tumors. -Topical minoxidil has demonstrated decreased severity and duration of alopecia but does not prevent it entirely -The nurse provides information about alopecia and supports the patient and family in coping with changes in body image. -The patient is advised to use shampoos without detergents, menthol, salicylic acid, alcohol, or heavy perfume to minimize damage; avoiding hair color, perms and bleach, hot rollers or excessive heat, or aggressive hair brushing or combing

Helping Patients Cope with Alopecia -The nurse notes the presence of alopecia (hair loss), which is another form of tissue disruption common in patients with cancer who receive radiation therapy or chemotherapy. - In addition, the nurse assesses the psychological impact of this side effect on the patient and family. -The temporary or permanent thinning or complete loss of hair is a potential adverse effect of various radiation therapies and chemotherapeutic agents.

Helping Patients Cope with Alopecia -The extent of alopecia depends on the type, dose, and duration of therapy. -Combination chemotherapy is more likely to cause complete hair loss than monotherapy. -These treatments cause alopecia by damaging stem cells and hair follicles. -As a result, the hair is brittle and may fall out or break off at the surface of the scalp. -Hair loss may be patchy or total, involve scalp hair and body hair, although loss of body hair is less frequent

CHEMOTHERAPY [GI SYSTEM] -NK1 antagonists and long-acting 5-HT3 antagonists are particularly useful in prevention of delayed nausea and vomiting. -Patients should also have medication at home for as-needed use for breakthrough nausea and vomiting; -options for breakthrough CINV include prochlorperazine, metoclopramide, olanzapine, lorazepam, dronabinol, and ondansetron (for patients who have not received the long-acting medication palonosetron) -For anticipatory CINV, benzodiazepines are most effective. Nonpharmacologic interventions, such as relaxation, can also be helpful in this setting

Hematopoietic System -Most chemotherapeutic agents cause myelosuppression (depression of bone marrow function), resulting in decreased production of blood cells. -Myelosuppresion decreases the number of WBCs (leukopenia), red blood cells (RBCs) (anemia), and platelets (thrombocytopenia) and increases the risk of infection and bleeding -Depression of these cells is a common reason for decreasing the dose of the chemotherapeutic agents. -Monitoring blood cell counts frequently is essential because it allows strategies to be implemented to protect patients from infection and injury. -

Hematopoietic stem cells transplantation -Many malignancies exhibit a dose-related response to chemotherapy; by increasing the dose of chemotherapy, the number of malignant cells destroyed is increased. -The dose of chemotherapy that is delivered is limited by the toxicity, specifically myelosuppression -The use of bone marrow or stem cells from either the patient (autologous) or from a donor (allogeneic) allows the bone marrow to be "rescued" from the toxic effects of the chemotherapy, therefore allowing higher doses of chemotherapy to be delivered safely

Hematopoietic stem cells transplantation -This method of collection uses apheresis methods to collect donor peripheral blood stem cells (PBSCs) for reinfusion. This is a safer and more cost-effective means of collection, rather than the traditional harvesting of marrow.

Hematopoietic system -other agents, called colony-stimulating factors (granulocyte colony-stimulating factor [G-CSF], granulocyte-macrophage colony-stimulating factor [GM-CSF], and erythropoietin [EPO]), can be administered after chemotherapy. -G-CSF and GM-CSF stimulate the bone marrow to produce WBCs, including neutrophils, at an accelerated rate, thus decreasing the duration of neutropenia -Neutropenia= presence of abnormally few neutrophils in the blood, leading to increased susceptibility to infection. [undesirable side effect of cancer treatment.] -GCSF decreases the episodes of infection and reduce the need for antibiotics, allowing for timelier cycling of chemotherapy with less need for dose reductions.

Hematopoietic system -Recent evidence has demonstrated that the use of ESAs in certain malignancies, including head and neck, nonsmall cell lung, lymphoid, cervical, and breast cancers, has resulted in decreased survival rates. -ESAs is not recommended in those diseases when the goal is cure -Other studies have demonstrated an increase in cardiac events, including cerebrovascular events and myocardial infarction, when hemoglobin (Hgb) targets of greater than 12 mg/dL were used. -

NURSING MANAGEMENT IN CHEMO;[TARGETED THERAPIES] -CHEMO-As a result, both healthy and malignant cells are subject to harmful systemic effects of treatment. -Targeted therapies seek to minimize the negative effects on healthy tissues by disrupting specific cancer cell functions, such as malignant transformation, communication pathways (also called cell signaling or signal transduction), processes for growth and metastasis, as well as genetic coding. -Many of the drugs targeting these kinases and growth factors are taken orally, and adherence is critical to response.

IMMUNORHERAPY -critical in preventing, controlling, and eliminating cancer. -Malignancy develops as a result of multiple mechanisms of immune failure or suppression -Immune therapies, including cytokines, vaccines, and checkpoint inhibitors, were developed in an attempt to restore or stimulate the body's own immune response to treat the cancer. -Cytokines, including interferon (IFN) alpha and interleukin-2 (IL-2), have been in use for many years in the treatment of melanoma. -They both have significant side effects, which have limited widespread use. -Eight percent of patients treated with IFN experience fever and fatigue. -Psychiatric side effects are also common, including depression (45%) with rare reports of suicide. -GI side effects include diarrhea, nausea, and anorexia

IMMUNOTHERAPY -High-dose IL-2 is associated with capillary leak syndrome leading to hypotension, which may require vasopressor support. -Flu-like symptoms are also seen. -These patients require expert nursing care and vigilant monitoring -Vaccines are used to stimulate the immune system to kill malignant cells. -Vaccines are also used to prevent cancer-causing infections (hepatitis, HPV) -Sipuleucel-T (Provenge®) is an FDA-approved vaccine for the treatment of advanced prostate cancer. -Side effects, including chills, fever, and fatigue, are common in the first 24 hours

IMMUNOTHERAPY -Three checkpoint inhibitor antibodies are approved for use in the United States, and a number of others are in development: -ipilimumab, which blocks CTLA-4; and pembrolizumab and nivolumab, which block PD-1 -Both nivolumab and pembrolizumab have shown durable response rates in advanced melanoma, renal cell carcinoma, and nonsmall cell lung cancer (requires expert care and management) -. Immune-related adverse events (irAEs) are a result of immune system stimulation and resemble autoimmune disorders, including colitis, pneumonitis, hypophysitis (endocrinopathies), hepatitis, and skin rashes.

IMPROVING BODY IMAGE -The nurse identifies potential threats to the patient's body image and assesses the patient's ability to cope with the many assaults to body image that he or she experiences throughout the course of disease and treatment. -Threats to self-concept are enormous as the patient faces the realization of illness, disfigurement, possible disability, and possible death. -To accommodate treatments or because of the disease, many patients with cancer are forced to alter their lifestyles. -Priorities and values change when body image is threatened. -Disfiguring surgery, hair loss, cachexia, skin changes, altered communication patterns, and sexual dysfunction are some of the devastating results of cancer and its treatment that threaten the patient's self-esteem and body image.

IMPROVING BODY IMAGE -A positive approach is essential when caring for patients with altered body image. -To help the patient retain control and positive self-esteem, it is important to encourage independence and continued participation in self-care and decision-making. -The patient is assisted to assume those tasks and participate in those activities that are personally of most value. -Any negative feelings that the patient has or threats to body image should be identified and discussed. -The nurse serves as a listener and counselor to both the patient and the family. -Referral to a support group can provide the patient with additional assistance in coping with the changes resulting from cancer or its treatment. -In many cases, cosmetologists can provide ideas about hair or wig styling, makeup, and the use of scarves and other head coverings to help with body image concerns.

Helping Patients Cope with Alopecia -The patient is encouraged to acquire a wig or hairpiece before hair loss occurs, so that the replacement matches the patient's own hair. -Use of attractive scarves and hats may make the patient feel less conspicuous. -The nurse can refer the patient to supportive programs, such as "Look Good, Feel Better," offered by the American Cancer Society. -The scalp should be protected from cold and sun with hats, scarves, wigs, and sunscreen; eye protection (sunglasses) is also important, especially if eyelashes are lost. -Knowledge that hair usually begins to regrow after therapy is completed may comfort some patients, although patients must be prepared that the color and texture of the new hair may be different.

IMPROVING NUTRITIONAL STATUS -Assessment of the patient's nutritional status is an important nursing role. -Impaired nutritional status may contribute to disease progression, decreased survival, immune incompetence, increased incidence of infection, delayed tissue repair, diminished functional ability, decreased capacity to continue antineoplastic therapy, increased length of hospital stay, and impaired psychosocial functioning. -Altered nutritional status, weight loss, and cachexia (muscle wasting, emaciation) are complex states and may be secondary to decreased protein and caloric intake, metabolic or mechanical effects of the cancer, systemic disease, side effects of the treatment, or the patient's emotional status.

IMPROVING NUTRITIONAL STATUS -The nursing assessment of nutritional status includes monitoring the patient's weight and caloric intake consistently. -Other information obtained by assessment includes diet history, any episodes of anorexia, changes in appetite, situations and foods that aggravate or relieve anorexia, and medication history. -Difficulty in chewing or swallowing is identified, and the presence of nausea, vomiting, or diarrhea is noted. -The patient should also be asked about the ability to prepare and obtain food to assist in identifying the need for additional resources.

IMPROVING NUTRITIONAL STATUS -Clinical and laboratory data useful in assessing nutritional status include anthropometric measurements (triceps skin fold and middle-upper arm circumference), serum protein levels (albumin, prealbumin, and transferrin), serum electrolytes, lymphocyte count, hemoglobin levels, hematocrit, urinary creatinine levels, and serum iron levels.

External Radiation -Kilovoltage therapy devices deliver the maximal radiation dose to superficial lesions, such as lesions of the skin and breast. -linear accelerators and betatron machines produce higher-energy x-rays and deliver their dosage to deeper structures with less harm to the skin and less scattering of radiation within the body tissues. -external radiation, the total radiation dose is delivered over several weeks to allow healthy tissue to repair and to achieve greater cell kill by exposing more cells to the radiation as they begin active cell division.

Internal radiation (brachytheraphy) -delivers a high dose of radiation to a localized area -selected on the basis of its half-life, which is the time it takes for half of its radioactivity to decay. -can be implanted by means of needles, seeds, beads, or catheters into body cavities (e.g., vagina, abdomen, pleura) or interstitial compartments (e.g., breast). -the farther the tissue is from the radiation source, the lower the radiation exposure. -Brachytherapy may also be administered orally, as with the isotope iodine-131, which is used to treat thyroid carcinomas. -

Intracavitary Radiation -used frequently to treat gynecologic cancers. -radioisotopes are inserted into applicators specially positioned in the cervix and vagina, after the position is verified by x-ray -remain in place for a prescribed time period and then are removed. -maintained on bed rest and carefully log-rolled to prevent displacement of the intracavitary delivery device. -The head of the bed must not be elevated greater than 15 degrees due to the risk of perforating the uterus with the appliance -Low-residue diets and antidiarrheal agents, such as diphenoxylate (Lomotil), are provided to prevent bowel movements during therapy that might displace the radioisotopes.

Intracavitary radiation -PCA for pain management -Patients are at risk for: atelectasis, pressure ulcers, and DVT due to bed rest so preventative measures, including incentive spirometry, a pressure-relieving mattress, sequential compression devices, and prophylactic anticoagulation, are essential to preventing these complications.

MAINTAINING SKIN INTEGRITY -Some of the most frequently encountered disturbances of tissue integrity, in addition to stomatitis, include skin and tissue reactions to radiation therapy, alopecia, and metastatic skin lesions. -Patients with skin and tissue reactions to radiation therapy require careful skin care to prevent further skin irritation, drying, and damage. -The skin over the affected area is handled gently; avoiding rubbing and use of hot or cold water, soaps, powders, lotions, and cosmetics. -Patients may avoid tissue injury by wearing loose-fitting, cotton clothes and avoiding clothes that constrict, irritate, or rub the affected area.

MAINTAINING SKIN INTEGRITY -If blistering occurs, care is taken not to disrupt the blisters, thus reducing the risk of introducing bacteria. -Moisture- and vapor-permeable dressings, such as hydrocolloids and hydrogels, are helpful in promoting healing and reducing pain. -Aseptic wound care is indicated to minimize the risk for infection and sepsis. -Topical antibiotics, such as 1% silver sulfadiazine cream (Silvadene), may be prescribed for use on areas of moist desquamation (painful, red, moist skin). -As many cancer treatments cause photosensitivity, patients must be counseled on sun protection and use of sunscreen

MAINTAINING SKIN INTEGRITY -The nurse assesses the patient with cancer for any skin problems. -Maintaining integrity of skin and tissue poses a problem for patients with cancer because of the effects of chemotherapy, radiation therapy, surgery, and invasive procedures carried out for diagnosis and therapy. -Targeted therapies are associated with cutaneous toxicity, including skin and nail changes -Nail changes can include loss of all or a portion of the nail, transverse ridges across the nail plate (Beau lines), and hyperpigmentation

MAINTAINING SKIN INTEGRITY -The EGFR inhibitors commonly cause skin rash appearing as acneform eruptions or a papulopustular rash -The rash can cause itching and discomfort. -Up to 30% of patients experience an infection due to alteration in skin integrity. -Treatment of EGFR inhibitor rash includes topical steroids and oral antibiotics -As part of the assessment, the nurse identifies which of these predisposing factors is present and assesses the patient for risk factors, including treatment type, nutritional deficits, bowel and bladder incontinence, immobility, immunosuppression, multiple skin folds, and changes related to aging. -The nurse notes the presence of skin lesions, ulcers, rashes, or ulcerations secondary to the tumor or the effects of treatment.

MANAGEMENT IN CANCER SURGERY -Cardiac risk factors that increase the risk of complications in non cardiac. surgery include: history of stroke heart failure angina MI Renal insufficiency diabetes

MANAGEMENT IN CANCER SURGERY -Pre-existing pulmonary disease can increase the risk for postoperative pneumonia and pleural effusions -risk for increased bleeding and may require additional testing prior to surgery to assess individual bleeding risk. -Elective surgery should be delayed until patient has an absolute neutrophil count of at least 1000 cells and a platelet count more than 50 platelets and more than 100 for any neurosurgery

MANAGEMENT -The range of possible treatment goals may include cancer prevention, complete eradication of malignant disease (cure), prolonged survival and prevention of progression (control), or relief of symptoms associated with the disease (palliation). -A number of factors are considered when determining a treatment plan, including the tumor type, stage, and grade; functional or performance status (PS) of the patient; comorbidities; and organ function. -PS= most important for determining eligibility; clinical trials, predicting prognosis. -two scales= Zubrod or ECOG -ECOG-range 0-4 [0=independent] [4=restricted to bed] -Karnofsky=other commonly used scale; ranges from 10(moribund)- 100(fully independent)

MANAGEMENT IN CANCER SURGERY -The effects of surgery on the patient's body image, self-esteem, and functional abilities are addressed. -Postoperative rehab plan is made before the surgery is performed -the nurse must complete a thorough preoperative assessment for factors that may affect the patient undergoing the surgical procedure, including medical history, prior cancer treatments, and any complications associated with those treatments. The nurse targets interventions to minimize the risk of complications

MANAGEMENT IN CANCER SURGERY -Nurse provides education and emotional support by assessing the needs of the patient and family -by discussing their fears and coping mechanisms -Nurse encourages the patient and family to take an active role in decision-making -If the patient or family asks about the results of diagnostic testing and surgical procedures, the nurse's response is guided by the information the provider has previously conveyed to the patient and family -The patient and family may also ask the nurse to explain and clarify information that the provider initially gave but that they did not grasp because they were anxious at the time.

MANAGEMENT IN CANCER SURGERY (After surgery) -nurse assess the patient's responses to surgery and monitors patients for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid/electrolyte imbalance, and organ dysfunction. -Postoperative teaching addresses decreasing the risk for complications, including deep vein thrombosis (DVT) and pneumonia, as well as education on wound care, activity, nutrition, and medication information.

MONITORING AND MANAGING BLEEDING AND HEMORRHAGE -When a hospitalized patient experiences bleeding, the nurse monitors blood pressure and pulse and respiratory rates every 15 to 30 minutes. -Serum hemoglobin and hematocrit are monitored carefully for changes indicating blood loss. -The nurse tests all urine, stool, and emesis for occult blood. -Neurologic assessments are performed to detect changes in orientation and behavior. -Headaches reported by the patient or abnormal neurologic findings must be reported to the provider immediately as even subtle signs may indicate an intracranial hemorrhage. -The nurse administers fluids and blood products as prescribed to replace any losses.

MONITORING AND MANAGING BLEEDING AND HEMORRHAGE -One unit of platelets is approximately 50 to 70 mL; in general, four to six units are pooled for a platelet transfusion and infused according to the patient's tolerance. -The platelet transfusion is anticipated to increase the platelet count 5,000 to 10,000/mL per unit.

MONITORING AND MANAGING BLEEDING AND HEMORRHAGE -Thrombocytopenia often results from bone marrow depression after certain types of chemotherapy and radiation therapy. -Tumor infiltration of the bone marrow can also impair the normal production of platelets. - In some cases, platelet destruction is associated with an enlarged spleen (hypersplenism) and abnormal antibody function, which occur with leukemia and lymphomA -

MONITORING AND MANAGING BLEEDING AND HEMORRHAGE -The nurse administers platelet transfusions as ordered and monitors for signs of transfusion reaction, including fever, chills, urticaria, and shortness of breath. -In limited circumstances, the nurse may administer Interluekin (IL)-11 (Oprelvekin), which has been approved by the U.S. Food and Drug Administration (FDA) to prevent severe thrombocytopenia and to reduce the need for platelet transfusions after myelosuppressive chemotherapy in patients with nonmyeloid malignancies. -In some instances, the nurse teaches the patient or family members to administer IL-11 in the home (Wyeth, 2013).

Minimizing the Risk of Infection in Neutropenic Patients. -Hand hygiene and appropriate general hygiene are critical to reduce exposure to potentially harmful bacteria and to eliminate environmental contaminants. -Invasive procedures, such as injections, vaginal or rectal examinations, rectal temperatures, and surgery, are avoided. -The patient is encouraged to cough and to perform deep-breathing exercises frequently to prevent atelectasis and other respiratory problems. -Prophylactic antimicrobial therapy may be used for patients who are expected to be profoundly immunosuppressed and at risk for certain infections, such as patients undergoing autologous or allogeneic stem cell transplant and patients with acute leukemia. -The nurse teaches the patient and family to recognize signs and symptoms of infection that should be reported, performs effective hand hygiene, uses antipyretics, maintains skin integrity, and administers hematopoietic growth factors when indicated.

MONITORING AND MANAGING BLEEDING AND HEMORRHAGE -The nurse assesses the patient with cancer for factors that may contribute to bleeding. -Bleeding may result from a reduction in the quantity or quality of platelets, a decrease in clotting factors, or from DIC -Treatment-related factors include bone marrow suppression from radiation, chemotherapy, and other medications that interfere with coagulation and platelet functioning, such as aspirin and other nonsteroidal anti-inflammatory medications, dipyridamole, heparin, or warfarin (Coumadin).

MONITORING AND MANAGING INFECTION AND SEPSIS -the nurse assesses risk factors for infection and observes for clinical signs and symptoms, as infection is the leading cause of death in cancer patients. -nurse monitors laboratory studies to detect early changes in WBC counts. -Common sites of infection, such as the oropharynx, skin, perianal area, urinary tract, GI tract, and respiratory tract, are assessed frequently. -The typical signs of infection (swelling, redness, drainage, and pain) may not occur in immunosuppressed patients because of a diminished local inflammatory response. -Fever or localized tenderness may be the only sign of infection. -The nurse also monitors the patient for sepsis, particularly if invasive catheters or venous access devices are in place.

MONITORING AND MANAGING INFECTION AND SEPSIS -WBC function is often impaired in patients with cancer. -there are two types of WBCs: granulocytes (neutrophils, eosinophils, basophils) and agranulocytes (lymphocytes, monocytes, macrophages -The neutrophils, totaling 60% to 70% of the body's total WBCs, play a major role in combating infection by engulfing and destroying microorganisms in a process called phagocytosis. -A decrease in circulating WBCs is referred to as leukopenia. Granulocytopeniaor neutropenia is a decrease in neutrophils

NURSING ALERT -Fever is often the only sign of infection in immunocompromised patients. -Although fever may be related to a variety of noninfectious conditions, including the underlying cancer, any temperature of 38.3°C (100.9°F) or higher or a sustained temperature of 38.0°C (100.4°F) for 1 hour is reported and addressed promptly (NCCN, 2016b).

Managing Patients with Febrile Neutropenia. -Empiric antibiotics are initiated to treat infections immediately after cultures are obtained. -The term empiric antibiotics refer to the use of broad-spectrum antibiotics used to treat infection before a definitive organism is identified. -Often, Gram stains are ordered along with cultures to assist providers in identifying the most appropriate antibiotic. - Empiric antibiotics have been employed due to the high incidence of mortality associated with untreated infection in neutropenic patients.

-Gram-positive bacteria (Streptococcus and Staphylococcus species) and gram-negative organisms (Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa) are the most frequently isolated causes of infection. -Fungal organisms, such as Candida albicans, also contribute to the incidence of serious infection. -Viral infections in immunocompromised patients are caused most commonly by herpes viruses and respiratory viruses.

Managing Patients with Febrile Neutropenia. -A fever in a patient with neutropenia is considered an emergency due to the high mortality rate associated with sepsis in neutropenic patients. -Hospitalized patients who are neutropenic and become febrile are assessed immediately for infection. -Cultures of blood, sputum, urine, stool, catheter, or wounds are obtained. -In addition, a chest x-ray is often included to assess for pulmonary infections. -If a patient is at home and develops neutropenic fever, the patient is instructed to notify their health care provider and seek medical attention immediately.

Managing Patients with Febrile Neutropenia. -Broad-spectrum antibiotic coverage or empiric therapy most often includes a combination of medications to defend the body against the major pathogenic organisms (both gram-positive and gram-negative). -It is important for the nurse to administer these medications promptly, immediately after two sets of blood cultures are obtained, according to the prescribed schedule, to achieve adequate blood levels of the medications (NCCN, 2016b).

Minimizing the Risk of Infection in Neutropenic Patients. -Strict asepsis is essential when handling IV lines, catheters, and other invasive equipment. -Patients are advised to minimize contact with anyone who might be sick and to avoid crowds. -Patients with profound immunosuppression, such as allogeneic HSCT recipients or patients with acute leukemia, should be placed in single rooms where the air is filtered. -To reduce the risk of foodborne illnesses, patients are educated to avoid raw meat, eggs, or fish; deli meats; unroasted raw nuts or nuts in the shell; miso products; raw grain products; unpasteurized milk products; and soft cheese, cheese with uncooked vegetables, or cheese with mold. -Fruits and vegetables must be washed well, eliminating soft fruits such as berries that are difficult to wash.

NURSING INTERVENTIONS PREVENTING/MINIMIZING FATIGUE -the nurse also addresses factors that contribute to fatigue, such as poor nutrition, pain, nausea, and depression, and implements pharmacologic and strategies to manage these symptoms. -The nurse provides nutrition counseling to patients who are not eating enough calories or protein. -Small, frequent meals require less energy for digestion. -The nurse monitors the patient for deficiencies in serum hemoglobin and hematocrit and administers blood products or ESAs as prescribed.

NURSING INTERVENTIONS PREVENTING/MINIMIZING FATIGUE -In addition, the nurse monitors the patient for alterations in oxygenation and electrolyte balances. - Physical therapy and assistive devices are beneficial for patients with impaired mobility. -Studies have evaluated the use of psychostimulants, such as methylphenidate and modafinil, for the treatment of fatigue with mixed results; m -more data are needed before these interventions can be recommended safely

The major goals for the patient may include -relief of fatigue, -absence of complications, -management of stomatitis, -maintenance of nutrition, -body image, -relief of pain, and -effective progression through the grieving process.

NURSING INTERVENTIONS PREVENTING/MINIMIZING FATIGUE -Cancer-related fatigue is an unusual, distressing, persistent, subjective sense of physical, cognitive, or emotional tiredness related to cancer or cancer treatment and not proportional to recent activity but interfering with usual activity. -Fatigue is a prevalent symptom that most patients experience at some point along their cancer experience.

NURSING INTERVENTIONS PREVENTING/MINIMIZING FATIGUE -Fatigue is a subjective symptom that must be assessed in a systematic way, similarly to pain, relying on the patient's self-report. -The nurse should ask the patient to describe the severity of the fatigue. -The patient can use a scale of 0 to 10, with 0 being no fatigue and 10 being severe fatigue, or patients can simply state none, mild, moderate, or severe. -the nurse should also assess the onset of fatigue as well as aggravating and alleviating factors, including physiologic and psychological stressors that can contribute to fatigue, such as pain, nausea, dyspnea, constipation, fear, and anxiety.

NURSING INTERVENTIONS PREVENTING/MINIMIZING FATIGUE -The nurse assesses for feelings of weariness, weakness, lack of energy, inability to carry out necessary and valued daily functions, lack of motivation, and inability to concentrate. -The patient may become less verbal and may appear pale, with relaxed facial musculature. -The nurse helps the patient and family understand that fatigue is an expected side effect of cancer and cancer treatment. -Fatigue may be exacerbated by the stress of coping with cancer. -It does not always signify that the cancer is advancing or that the treatment is failing.

NURSING INTERVENTIONS PREVENTING/MINIMIZING FATIGUE -The nurse also counsels on sleep hygiene, including not staying in bed if the patient is not sleeping; -going to bed only when sleepy and at the same time every night; -using the bed only for sleep and sexual activity; -avoiding daytime napping or, if needed, limiting naps to 30 minutes; -avoiding caffeine, nicotine, and alcohol after noon; -and using a relaxing routine within 2 hours of going to bed, such as a warm bath or shower, reading, or listening to music

NURSING INTERVENTIONS PREVENTING/MINIMIZING FATIGUE -The patient is encouraged to maintain as normal a lifestyle as possible by continuing with activities that he or she values and enjoys. -Prioritizing necessary and valued activities can help the patient plan for each day. -The patient and family are encouraged to plan to reallocate responsibilities, such as attending to childcare, cleaning, and preparing meals. -Patients who are employed full-time may need to reduce the number of hours worked each day or week. -The nurse helps the patient and family cope with these changing roles and responsibilities.

NURSING INTERVENTIONS PREVENTING/MINIMIZING FATIGUE -Nursing strategies are implemented to minimize fatigue or to help the patient cope with existing fatigue. -Educational interventions and cognitive behavioral therapies, including providing anticipatory guidance that fatigue is an expected side effect of cancer treatment, have been shown to reduce the severity of cancer-related fatigue. - Helping the patient identify sources of fatigue aids in selecting appropriate and individualized interventions.

NURSING INTERVENTIONS PREVENTING/MINIMIZING FATIGUE -Ways to conserve energy are developed to help the patient plan daily activities. -Alternating periods of rest and activity are beneficial. -Strong evidence exists to support that regular exercise may decrease fatigue and facilitate coping, whereas lack of physical activity and "too much rest" can actually contribute to deconditioning and associated fatigue -Yoga has also shown to improve cancer-related fatigue -The nurse assists in educating the patient on local resources for exercise and yoga

CHEMO; REPRODUCTIVE -Banking of sperm is recommended for males of reproductive age before treatments are initiated. -Sperm banking requires daily sperm collections for 2 to 3 days in order to collect a sufficient sample -Women should be counseled regarding options for fertility preservation prior to initiating treatment. -Embryo cryopreservation is the most well-established method for fertility preservation. -Fertility preservation options for women require more time (2 to 6 weeks) and may result in cancer treatment delays, which may impact overall outcomes -Prior to initiating treatment, patients and their partners need to be informed about potential changes in reproductive and sexual function resulting from chemotherapy. -They are advised to use reliable methods of birth control while receiving chemotherapy and not to assume that sterility has resulted.

NURSING MANAGEMENT IN CHEMO; -Chemotherapeutic agents have systemic effects on normal cells as well as malignant ones, which means that these problems are often widespread, affecting many body systems. -Common side effects seen with chemotherapy include myelosuppression, alopecia, nausea and vomiting, anorexia, and fatigue. The nursing care specific to these side effects is discussed in the nursing process section on page 181. -

NURSING MANAGEMENT IN IMMUNOTHERAPY -monitoring should include complete blood counts, liver function tests (LFTs) and metabolic panels, and thyroid function tests. -For fatigue and nonspecific syndromes, cortisol should be checked to rule out adrenal insufficiency; and -in men, testosterone should be checked as it may be low as a result of pituitary suppression -Patients must be counseled to report any signs of diarrhea, bloody stool, or abdominal pain promptly as colitis can be life threatening if untreated. -Corticosteroids are the primary treatment, and patients may have to be on steroids for prolonged periods; the nurse should provide education on short- and long-term effects of steroids and the importance of taking steroids with food to minimize stomach upset.

NURSING MANAGEMENT IN IMMUNOTHERAPY -Referral for home care may be indicated to monitor the patient's responses to treatment and to continue to reinforce patient and family teaching. -the nurse assesses the patient's and family members' technique in administering medications -nurse collaborates with providers, third-party payers, and pharmaceutical companies to help the patient obtain reimbursement for home administration of these therapies. -nurse also reminds the patient about the importance of keeping follow-up appointments with providers and assesses the patient's need for changes in care.

IMMUNOTHERAPY -Skin-related side effects often occur first. -Colitis is seen after 4 to 6 weeks; and -hepatitis and endocrinopathies occur later, as late as 12 to 24 weeks into treatment. -Prompt initiation of steroids is essential to avoid severe, life-threatening autoimmune effects.

NURSING MANAGEMENT IN IMMUNOTHERAPY -require careful monitoring and thorough patient education regarding reportable side effects and self-care -Adverse effects, including flu-like symptoms such as fever, chills, myalgia,nausea, and vomiting, as seen with IFN therapy, may not be life threatening. -implement supportive care measures, such as NSAIDs for flu-like symptoms and antiemetics for nausea and vomiting to relieve symptoms. -Other life-threatening adverse effects (e.g., capillary leak syndrome, pulmonary edema, hypotension) may occur with IL-2 therapy, requiring aggressive fluid resuscitation and, at times, vasopressors (refer to Chapter 54for details on managing shock)

MANAGEMENT IN CANCER SURGERY - Patients undergoing surgery for cancer require general perioperative nursing care, along with specific care related to age, organ impairment, nutritional deficits, disorders of coagulation, and altered immunity that may increase the risk of postoperative complications. -Combining other treatment methods, such as radiation and chemotherapy, with surgery also contributes to postoperative complications, such as infection, impaired wound healing, altered pulmonary or kidney function, and the development of venous thromboembolism (VTE), also known as DVT. -Some cancer types result in an increase in circulating procoagulants, which can significantly increase the risk for DVT. Patients with cancer account for 20% of all DVT cases

Nursing Alert -Approximately 50% of patients with DVT are asymptomatic. -The nurse should inquire about an ache or pain in the calf that is aggravated by standing or walking. -In addition, it is important to assess for asymmetry of the limbs as slight swelling may be noted as well as erythema and warmth of the involved extremity. -Venous distention in the affected limb that persists despite elevation of the extremity may be noted. -Patients may also present with low-grade fever and tachycardia.

Nursing Management in Stem Cell Transplantation -The patient requires support with blood products and hematopoietic growth factors -Potential infections may be bacterial, viral, fungal, or protozoan in origin. -Renal complications may arise from the nephrotoxic chemotherapy agents used in the conditioning regimen or those used to treat infection (amphotericin B, aminoglycosides) -Tumor lysis syndrome (Box 6-6) is an uncommon occurrence with conditioning as most patients do not have a large disease burden at the time of transplant. Acute tubular necrosis is a risk following conditioning therapy. -

Nursing Management in Stem Cell Transplantation -GVHD requires skillful nursing assessment to detect early effects on the skin, liver, and GI tract, including red maculopapular rash commonly found on the palms of the hands and soles of the feet, elevated LFTs, weight gain, jaundice, right upper quadrant pain, diffuse abdominal pain, early satiety, and diarrhea. -Diarrhea resulting from GVHD may be of large volume; therefore, all stools must be measured and monitored for the presence of blood. -VOD resulting from the conditioning regimens used in HSCT can result in fluid retention, jaundice, abdominal pain, ascites, tender and enlarged liver, and encephalopathy

Nursing Management in Stem Cell Transplantation -In the pretransplant phase, the nurse educates the patient about what to expect, pretransplant testing, and finding a donor -When the patient is admitted for high-dose chemotherapy with or without total body irradiation, the nurse educates the patient about expected side effects, expected onset and recovery, and critical self-care measures to decrease the risk of infection. -The acute toxicities of nausea, vomiting, diarrhea, mucositis, myelosuppression, and hemorrhagic cystitis require close monitoring and constant attention by the nurse. -

Nursing Management in Stem Cell Transplantation -Nursing management during the bone marrow or stem cell infusions consists of monitoring the patient's vital signs and blood oxygen saturation; assessing for adverse effects, such as fever, chills, shortness of breath, chest pain, cutaneous reactions (hives), nausea, vomiting, hypotension or hypertension, tachycardia, anxiety, and taste changes; and providing ongoing support and patient teaching. -Throughout the period of bone marrow aplasia (inability to create new cells) until engraftment of the new marrow occurs, the patient is at high risk for death from sepsis and bleeding.

PROMOTING NUTRITION -If adequate nutrition cannot be maintained by oral intake, nutritional support via the enteral route may be necessary. -Short-term nutritional supplementation may be provided through a nasogastric tube. -However, if nutritional support is needed for longer than several weeks, a gastrostomy or jejunostomy tube may be inserted. -The patient and family are taught to administer enteral nutrition in the home.

PROMOTING NUTRITION -If malabsorption is a problem, enzyme and vitamin replacement may be instituted. -Additional strategies include changing the feeding schedule, using simple diets, and relieving diarrhea. -If malabsorption is severe, parenteral nutrition may be necessary. -Parenteral nutrition can be administered in several ways: by a long-term venous access device (e.g., right atrial catheter), by an implanted venous port, or by a peripherally inserted central catheter (PICC) -The nurse teaches the patient and family to care for venous access devices and to administer parenteral nutrition when appropriate. -Home care nurses may assist with or supervise parenteral nutrition administration in the home.

PROMOTING NUTRITION -maintain adequate nutrition through the oral route. -High calorie/high protein supplements should be encouraged -Food should be prepared in ways that make it appealing. -Unpleasant smells are avoided. -Family members are included in the plan of care to encourage adequate food intake. -The patient's preferences, as well as physiologic and metabolic requirements, are considered when selecting foods. -Small, frequent meals are provided with supplements between meals. -Patients often tolerate larger amounts of food earlier in the day rather than later, so meals can be planned accordingly

PROMOTING NUTRITION -To avoid early satiety, the patient should avoid drinking fluids while eating. -Oral hygiene before mealtime often makes meals more pleasant. -It is important to assess and manage pain, nausea, and other symptoms that may interfere with nutrition. -Medications, such as corticosteroids, dronabinol, and progestational agents such as megestrol acetate, have been used successfully as appetite stimulants -Prokinetic agents, such as metoclopramide, are used to increase gastric emptying in patients with early satiety and delayed gastric emptying.

-Primary prevention efforts focus on preventing or delaying onset of cancer. -Secondary prevention focuses on the early detection of cancer with the goal of identifying cancer in early stages before symptoms develop. -Tertiary prevention includes the management of the disease and prevention of progression to later stages.

Primary Prevention -Nurses can use their teaching and counseling skills to encourage participation in cancer prevention programs, minimize exposure to known carcinogens, and to adopt healthy lifestyles, including avoiding all forms of tobacco; maintaining a healthy weight; performing regular exercise (150 min/wk); eating a diet rich in fruits and vegetables (at least five servings per day); limiting red meat, high fat, and processed foods; limiting alcohol; using sun protection; getting regular checkups; and being familiar with their own family history and personal cancer risks

Protecting Skin and oral mucosa -If temporary skin markings were applied to facilitate external radiation treatments, warn the patient not to remove the markings. -Avoid any perfumed lotion or powder; avoid applying makeup to the treatment field. -Emollients such as Aquaphor® may be used as directed by the radiation oncologist to soothe and moisturize irritated skin. -However, even approved emollients should not be used up to 4 hours before the treatment time. -Electric razors should be used for shaving, but aftershave products should be avoided -avoid constrictive clothing that may irritate skin. -Loose, cotton clothing is usually most comfortable. -avoiding sun exposure, wind, extreme temperatures, heating lamps, heating pads, and ice packs to the area being treated—these are all potential sources of thermal injury. Avoid itching skin and avoid applying tape to radiated areas to minimize trauma to the skin

Protecting oral mucosa -Gentle oral hygiene is essential to remove debris, prevent irritation, and promote healing -If systemic symptoms, such as weakness and fatigue, occur, the patient may need assistance with activities of daily living and personal hygiene -In addition, the nurse offers reassurance by explaining that these symptoms are a result of the treatment and do not represent deterioration or progression of the disease.

Providing patient education -To answer questions and allay fears about the effects of radiation on the tumor and on the patient's normal tissues and organs, the nurse explains the procedure for delivering radiation and describes the equipment, the duration of the procedure (often minutes only), the methods for immobilizing the patient during the procedure, and the sensory experience, including the absence of pain, during the procedure. -If a radioactive implant is used, the nurse informs the patient and family about the restrictions placed on visitors and health care personnel and other radiation precautions. -Patients with seed implants may be able to return home because the radiation exposure to others is minimal -

Protecting skin and oral mucosa -regularly assesses the patient's skin, oral mucosa, nutritional status, and general feeling of well-being. -95% of patients receiving radiation experience radiation dermatitis. -educate the patient on early identification of symptoms and self-care guidelines to minimize further damage -The skin in the radiation field must be protected from irritation -patient is instructed to avoid using ointments, lotions, or powders on the treated area.patient is instructed to avoid using ointments, lotions, or powders on the treated area. -gently cleanse the skin with lukewarm water and a mild, nondeodorant soap using the fingertips or a soft washcloth (no scrubbing) and then gently pat the area dry.

Nursing Management in Stem Cell Transplantation -Pulmonary complications, such as pulmonary edema, interstitial pneumonia, and other pneumonias, often complicate the recovery after transplant. -Immunosuppressive agents, including cyclosporine, tacrolimus, and rapamycin, require close monitoring of blood levels and kidney function; doses are adjusted based on blood levels. -Patients also require education about timing of medication around blood draws and meals, as well as the potential for drug-drug interactions -

Providing Post-transplantation care -Ongoing nursing assessment and coordination of care in follow-up visits is essential to detect and manage late effects of therapy after HSCT, which occur 100 days or more after the procedure. -Late effects include infections (e.g., varicella zoster infection), restrictive pulmonary abnormalities, and recurrent pneumonias. -sterility may result -Chronic GVHD involves the skin, liver, intestine, esophagus, eyes, lungs, joints, and oral and vaginal mucosa.

PROMOTING NUTRITON -Interventions to reduce cachexia usually do not prolong survival or improve nutritional status significantly. -Optimal management of other symptoms that may be contributing, such as depression, anxiety, nausea or xerostomia, is critical to promoting improved nutritional intake. -Further study is needed to assess the effects of nutritional intervention on disease status and the patient's quality of life. -Before invasive nutritional strategies are instituted, the nurse should assess the patient carefully and discuss goals of care and options with the patient and family.

RELIEVING PAIN -The nurse assesses the patient with cancer for the source and site of pain. -In cancer, pain and discomfort may be related to underlying disease, pressure exerted by the tumor, diagnostic procedures, or the cancer treatment itself. -As in any other situation involving pain, cancer pain is affected by both physical and psychosocial influences. -A comprehensive pain assessment is completed including onset, duration, location, quality or characteristics, quantity, aggravating and alleviating factors, associated symptoms, and the treatments that the patient has used to relieve pain.

RELIEVING PAIN -The nurse also assesses those factors that increase the patient's perception of pain, such as fear and apprehension, fatigue, anger, and social isolation. - Pain assessment scales are useful for assessing the patient's pain before pain-relieving interventions are instituted and for evaluating the effectiveness of these interventions.

RELIEVING PAIN -Various pharmacologic and nonpharmacologic options are available for managing cancer pain. -No reasonable approaches, even those that may be invasive, should be overlooked because of a poor or terminal prognosis. -The nurse helps the patient and family take an active role in managing pain. -The nurse provides education and support to correct fears and misconceptions about opioid use. -Inadequate pain control leads to suffering, anxiety, fear, immobility, isolation, and depression. -The goal, regardless of the patient's disease status, is to maximize quality of life and optimize functional ability by adequately managing pain.

Radiation dosage -dependent on the sensitivity of the target tissues to radiation and on the tumor size. -The lethal tumor dose is defined as the dose that will eradicate 95% of the tumor yet preserve normal tissue. -Repeated radiation treatments over time (fractionated doses) also allow for the periphery of the tumor to be reoxygenated repeatedly because tumors shrink from the outside inward. -This increases the radiosensitivity of the tumor, thereby increasing tumor cell death.

Radiation Toxicity -localized to the region being irradiated. -increased if concomitant chemotherapy is administered -Altered skin integrity is a common effect and can include alopecia (hair loss), erythema, and shedding of skin (desquamation) -Alterations in oral mucosa secondary to radiation therapy include stomatitis, xerostomia (dryness of the mouth), change and loss of taste, and decreased salivation. -entire GI mucosa may be involved, possibly resulting in esophageal irritation with chest pain and dysphagia. -- --Anorexia, nausea, vomiting, and diarrhea may occur if the stomach or colon is in the irradiated field. - ---k--k---Symptoms subside and GI re-epithelialization occurs after treatments have been completed; however, it may take several weeks for stomatitis to resolve. Xerostomia and taste changes may never return to normal.

Safety -emit radiation while the implant is in place, contacts with the health care team are guided by principles of time, distance, and shielding to minimize exposure of personnel to radiation. -The goal of nursing care for this population is to deliver safe, efficient care that meets the patients' needs in the shortest amount of time; in general, no more than 30 minutes per 8-hour shift. -The principle of distance means that the closer you are to the patient, the greater the radiation exposure. -When not providing direct care (e.g., when talking with the patient), stand at least 6 feet from the patient to minimize exposure -Organize activities outside the room when possible; for example, preparation of meals and medication -Shielding refers to the use of a lead shield to buffer the exposure to radiation. Often, the rooms that patients stay in may be lead-lined, or portable lead shields or aprons may be available to minimize exposure.

Safety Precautions (brachytherapy) -assigning the patient to a private room, posting appropriate notices about radiation safety precautions, having staff members wear dosimeter badges (to track cumulative radiation exposure), ensuring that pregnant staff members are not assigned to the patient's care, prohibiting visits by children or pregnant visitors, limiting visits from others to 30 minutes daily, and seeing that visitors maintain a 6-foot distance from the radiation source. -If the radiation implant becomes dislodged, the nurses' first priority is to ensure the safety of the patient. -Metal forceps and a lead-lined container should be available in the room -use the forceps to pick up the radiation source and place the source into the lead-lined contained, then contact radiation safety officer -patient, nurse, and room will be monitored for radioactivity using a Geiger counter. -The staff exposed should report to their Occupational Health department for an evaluation. -Nurses should refer to their institution's radiation safety committee's guidelines for specific measures.

Primary Prevention -immunization against cancer-associated viruses, such as hepatitis and HPV -For individuals at high risk for cancer, medications or prophylactic surgery may be recommended -Several clinical trials have been conducted to identify medications that may help reduce the incidence of certain types of cancer -For example, a number of studies have demonstrated that daily use of the medication tamoxifen can significantly reduce a woman's lifetime risk of developing breast cancer in high-risk populations (Cuzik et al., 2014). -may focus on the hazards of tobacco use or the importance of nutrition

Secondary Prevention -Nurses must be aware of factors such as race, cultural influences, access to care, provider-patient relationship, level of education, income, and age, which influence the knowledge, attitudes, and beliefs people have about cancer. -These factors also may affect the health-promoting behaviors people practice. -health education and health maintenance programs -Secondary prevention programs focus on early detection. -Nurses and providers must encourage people to comply with detection efforts as suggested

Risk factors for extravasation: -include small and/or fragile veins, lymphedema, obesity, impaired level of consciousness (LOC), history of multiple venipunctures, poor cannula size selection, and poor vein selection -occur as a result of accidental puncturing of the vein or with movement of the cannula itself due to patient activity or a poorly secured catheter. -Prolonged peripheral IV infusions of vesicants carry an increased risk of extravasation, and, therefore, vesicant infusions lasting more than 1 hour should be administered through a CVAD -

Strategies to decrease the risk of extravasation include: -Appropriate training of nurses following the ONS standards -Selection of appropriate vascular access location, including avoiding veins in the hand, wrist, or antecubital regions -Avoiding veins that are small and/or fragile -Avoiding an extremity with lymphedema or recent venipuncture -Use of the smallest size of cannula in the largest available vein -Use of a small bore plastic cannula that is 1.2 to 1.5 cm long -Use of a clear dressing -Avoiding the use of a butterfly needle

IMPROVING BODY IMAGE -Patients who experience alterations in sexuality and sexual function are encouraged to discuss concerns openly with the health care team and with their partners. -Alternative forms of sexual expression are explored with patients and their partners to promote positive self-worth and acceptance. -Nurses who identify serious physiologic, psychological, or communication difficulties related to sexuality or sexual function are in a key position to help patients and partners seek further counseling if necessary.

TEACHING PATIENTS SELF CARE -Many patients with cancer return home from acute-care facilities to receive treatment in the home or outpatient area. -The shift from the acute-care setting also shifts the responsibility for care to the patient and family. -As a result, family members and friends must assume increased involvement in patient care, which requires teaching that enables them to provide quality care. -Teaching initially focuses on providing information needed by the patient and family to address the most immediate care needs likely to be encountered at home.

TEACHING PATIENTS SELF-CARE -Side effects of treatments and changes in the patient's status that should be reported are reviewed verbally and reinforced with written information. -Strategies to deal with side effects of treatment are discussed with the patient and family. -Other learning needs are identified based on the priorities conveyed by the patient and family as well as on the complexity of care provided in the home. -Technologic advancements allow home administration of chemotherapy, parenteral nutrition, blood products, parenteral antibiotics, and parenteral analgesics as well as management of symptoms and care of vascular access devices.

TEACHING PATIENTS SELF-CARE -Although home care nurses provide care and support for patients receiving this advanced technical care, patients and families need instruction and ongoing support that allow them to feel comfortable and proficient in managing these treatments at home. -Follow-up visits and telephone calls from the nurse are often reassuring and increase the patient's and family's comfort in dealing with complex and new aspects of care. -Continued contact facilitates evaluation of the patient's progress and assessment of the ongoing needs of the patient and family.

MANAGEMENT IN CANCER SURGERY -Plans for discharge, follow-up and home care, and treatment are initiated as early as possible to ensure continuity of care from hospital to home or from a cancer referral center to the patient's local hospital and health care provider. -Patients and families are also encouraged to use community resources, such as the American Cancer Society, for support and information.

THROMBOCYTOPENIA -increased risk for infection and bleeding until blood cell counts return to normal. -Chronic anemia may occur commonly due to the cumulative effects of radiation and may be evidenced by shortness of breath, dizziness, fatigue, decreased oxygen saturation, and decreased activity tolerance. -

-Epigenetic changes result in a change in phenotype without a change in genotype. -Epigenetics are critical to the process of transcription regulation and gene expression (Miozzo, Vaira, & Sirchia, 2015). -Epigenetic changes include alterations in DNA methylation, histone modification, changes in chromatin, and noncoding RNA (ncRNA)-associated gene silencing. -These changes may result in overexpression or underexpression of genes (Lemoine, 2014; Harrington et al., 2013; Shao, Khokha, & Hill, 2013; Miozzo et al., 2015).

The following cellular changes are essential to carcino-genesis: 1)loss of sensitivity to growth inhibitory signals 2)evasion of apoptosis (programmed cell death) 3)limitless replicative potential 4)angiogenesis (growth of new blood vessels) 5)potential for metastatic/tissue invasion

Types of Stem Cell Transplantation (SCT) -Allogeneic stem cell transplant is used primarily for disease of the bone marrow, including acute leukemia and aplastic anemia, and depends on the availability of a human leukocyte antigen-matched donor. -A patient with one sibling has a 25% chance of having a matched-sibling donor -Prior to transplant, patients and potential donors undergo a thorough clinical assessment to evaluate eligibility

Types of Stem Cell Transplantation (SCT)

Types of Stem Cell Transplantation (SCT) -Autologous (from patient) -Allogeneic (from a donor other than the patient); either a related donor (i.e., family member) or a matched unrelated donor (national bone marrow registry, cord blood registry) -Syngeneic (from an identical twin)

Types of Stem Cell Transplantation (SCT) -Autologous hematopoietic SCT, or HSCT, is considered for patients with hematologic malignancies requiring treatment with myeloablative doses of chemotherapy (doses high enough to obliterate marrow function) to achieve cure or prolong survival. -Malignancies most commonly treated with autologous transplant include myeloma and lymphoma -In autologous transplant, cells are collected from the patient and preserved for reinfusion at a later date -Then the patient is treated with myeloablative chemotherapy and, in some cases, total body irradiation to eradicate any remaining tumor

Types of Stem Cell Transplantation (SCT) -When the new bone marrow becomes functional, producing RBCs, WBCs, and platelets, engraftment is considered complete (2 to 4 weeks) -The donor's healthy immune system is able to recognize the patient's malignancy as foreign and kill any remaining tumor cells. -This is referred to as the graft-versus-tumor effect. -However, patients can also experience graft versus host disease (GVHD) as a result of the donor's immune system (T cells) recognizing the recipient's tissues as foreign.

Types of Stem Cell Transplantation (SCT) -In nonmyeloablative allogeneic HSCT, the chemotherapy doses are lower and are aimed at suppressing the recipient's immune system to allow engraftment of donor bone marrow or PBSCs. -The lower doses of chemotherapy create less organ toxicity and, thus, can be offered to older patients or those with underlying organ dysfunction, for whom high-dose chemotherapy would be prohibitive. -Once the transplanted donor cells begin to grow and reproduce, a process referred to as engraftment, a graft-versus-disease effect results in which the donor's healthy immune system keeps the patient's cancer cells from growing.

Types of Stem Cell Transplantation (SCT) -The first 100 days after allogeneic HSCT are crucial for patients; the immune system and blood-making capacity (hematopoiesis) must recover sufficiently to prevent infection and hemorrhage. -Most acute side effects, such as nausea, vomiting, and mucositis, also resolve in the initial 100 days after transplantation -In addition to acute GVHD, patients are also at risk for hepatic venous occlusive disease (VOD) or hepatic sinusoidal obstruction syndrome (HSOS), a vascular injury to the liver caused by high-dose chemotherapy -

Types of Stem Cell Transplantation (SCT) -Incidence of VOD is as high as 30% -VOD can lead to acute liver failure and death and presents as painful hepatomegaly (enlarged liver), elevated bilirubin levels, ascites, and weight gain in the absence of other causes. -Coagulopathy and acute kidney failure can also accompany VOD. -Onset is within the first 20 days posttransplant.

Types of Stem Cell Transplantation (SCT) -There are no standard treatments for VOD; -defibrotide has shown promise with response rates of 30% to 60%. -Ursodiol has shown some efficacy in the preventative setting and is initiated prior to transplant in some institutions. -Fortunately, 70% of patients have resolution of VOD without intervention. -Supportive care includes maintaining fluid balance through strict monitoring of I/O and twice-daily weights, pain management, monitoring for signs of bleeding and administering blood products as ordered, and ensuring patient safety.

Types of Stem Cell Transplantation (SCT) -Syngeneic transplants use an identical twin as the donor. -Syngeneic transplants result in less incidence of GVHD and graft rejection; however, there is also less graft-versus-tumor effect to fight the malignancy. -For this reason, even when an identical twin is available for marrow donation, another matched sibling or even an unrelated donor may be the most suitable option to combat an aggressive malignancy

Types of Stem Cell Transplantation (SCT) -Before engraftment, patients are at high risk for infection, sepsis, and bleeding. -Side effects of the high-dose chemotherapy and total body irradiation can be acute and chronic. -Acute side effects include alopecia, hemorrhagic cystitis (inflammation of the bladder), nausea, vomiting, diarrhea, and severe stomatitis. -Chronic side effects include sterility, pulmonary dysfunction, cardiac dysfunction, cataracts, and liver disease

Types of Stem Cell Transplantation (SCT) -To prevent GVHD, patients receive immunosuppressant drugs, such as cyclosporine (Neoral), tacrolimus (FK 506, Prograf), or sirolimus (Rappamune) -In allogeneic transplant recipients, GVHD occurs when the T lymphocytes proliferating from the transplanted donor marrow or PBSCs become activated and mount an immune response against the recipient's tissues (skin, GI tract, liver). -T lymphocytes respond in this manner because they view the recipient's tissue as "foreign," immunologically different from what they recognize as "self" in the donor. -GVHD may occur acutely (within the first 100 days) or chronically (after 100 days

Understanding Cancer-Related Causes of Malnutrition -These changes lead to decreased appetite, decreased nutritional intake, and protein-calorie malnutrition. -Taste alterations may result from mineral (e.g., zinc) deficiencies, increases in circulating amino acids and cellular metabolites, or the administration of chemotherapeutic agents. -Patients undergoing radiation therapy to the head and neck may experience "mouth blindness" which is a severe impairment of taste. -Alterations in the sense of smell also alter taste; this is a common experience of patients with head and neck cancers.

Understanding Cancer-Related Causes of Malnutrition -Anorexia may occur because people feel full after eating only a small amount of food. -This is referred to as early satiety. -This sense of fullness occurs secondary to a decrease in digestive enzymes, abnormalities in the metabolism of glucose and triglycerides, and prolonged stimulation of gastric volume receptors, which convey the feeling of being full. -Psychological distress (e.g., fear, pain, depression, and isolation) throughout illness may also have a negative impact on appetite. -Patients may develop an aversion to food because of nausea and vomiting after treatment.

Nursing Alert A normal serum albumin is 3.5 to 5.2 g/dL or 35 to 52 g/L and gives the clinician a quick assessment of protein stores. In a seminal study by Seltzer et al. (1979), a sixfold increase in mortality was seen with an albumin level of less than 35 g/L, while additional studies associate serum albumin levels of less than 30 g/L with significant morbidity and mortality regardless of patient age and diagnosis (Jellinge, Henriksen, Hallas, & Brabrand, 2014). However, since albumin is degraded over 14 to 21 days, it is not a good measure for assessing recent nutritional deficits. Prealbumin has a half-life of 2 days and, therefore, is a better measure of response to dietary treatments. The normal reference range for prealbumin in males is 19 to 37 mg/dL, and in females, 17 to 31 mg/dL.

Understanding Cancer-Related Causes of Malnutrition -Most patients with cancer experience some weight loss during their illness. -Anorexia, malabsorption, and cachexia are examples of nutritional problems that commonly occur in patients with cancer; special attention is needed to prevent weight loss and promote nutrition. -Anorexia is defined as an involuntary loss of appetite. -Among the many causes of anorexia in patients with cancer is alterations in taste, manifested by increased salty, sour, and metallic taste sensations, and altered responses to sweet and bitter flavors.