Transcript Pain management. Nursing Care of the Client with Cancer. End

Pain Management
Safety, Security and Comfort Needs of the
Acutely Ill Client:
PAIN
The 5th Vital Sign
Definitions of Pain
 “Pain is whatever the experiencing
person says it is, existing whenever
he/she says it does.”
 “An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage or described in
terms of such damage.”
-Mc Caffery 1968
- Intl. Assoc. for the study of pain
Food for Thought
 Costs $100 Billion each year
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Longer hospitalization
Rehospitalizations
ER visits
Sick days
Permanent Disability
 Only 30% of cancer patients get adequate
pain relief
 15-20% of Americans have acute pain
 25-30% of Americans have chronic pain
 Leading cause disability for those < 45 y/o
The Mechanisms of Pain
 Transduction Transmission- movement of pain
impulses
 Perception- recognition of pain
 Modulation- activation
The Mechanisms of Pain
 Transduction Conversion of mechanical, thermal or
chemical stimulus into a neuronal action.
 Peripheral nerve sites- peripheral afferent nociceptor
(PAN)
 Action Potential causes movement of pain
stimulus What causes it?
 Nociceptive- Release of Chemicals
 Neuropathic- Abnormal processing of stimuli by
the nervous system
The Mechanisms of Pain
 Transmission- movement of pain
impulses from the site of transduction to
the brain.
 Transmission along the nociceptor fibers to
the level of the spinal cord.
 Dorsal horn processing. (Dermatomes)
 Transmission to the thalamus and the
cortex.
The Mechanisms of Pain
 Perception- recognition of pain
 However, there is no precise location where pain
perception occurs.
 Individualized
 Imagery is a good pain-reduction therapy.
 Subjective
 Sensory: Recognition that you have pain.
 Affective: Emotional responses to pain.
 Behavioral: How someone expresses or controls
pain.
 Cognitive: Person’s beliefs & attitudes about
pain.
 Sociocultural: Age, Gender, education level,
culture and support systems.
The Mechanisms of Pain
 Modulation- activation of descending
pathways that either inhibit or facilitate
effects on pain transmission.
Types of Pain
Nociceptive Pain
 Normal processing of stimuli that
damages or has the potential to
damage, normal tissues if prolonged.
 Different types of origins:
 Somatic Pain: Arises from bone, joint,
muscle, skin or connective tissue.
 Visceral Pain: Arises from visceral organs,
such as pancreas or stomach.
Somatic Pain
 Described as “achy”, stabbing, sharp
 Examples:
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Bone pain, fractures
Muscle tears, sprains
Joint pain
Soft tissue injury
Visceral Pain
 Diffuse and difficult to localize if d/t
obstruction of hollow viscus
 Sharp, aching when due to injury to other
visceral structures such as;
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Pancreatitis
Kidney Stones
Menstrual Cramps
Bowel Obstruction
Neuropathic Pain
 Multiple Pain Syndromes
 Often difficult to treat.
 Believed to be the abnormal firing of the
peripheral or central nervous system.
 Often described as burning, stinging,
shooting, traveling, or electric-like.
 Caused by phantom limb pain, complex
regional limb pain complex regional pain
syndromes, diabetic neuropathy, postherpetic neuralgia, or trigeminal
neuralgia
Comparing Nociceptive & Neuropathic
Pain
 Normal processing of
stimuli that damages
normal tissue.
 Responds to opioids or
nonopiods.
 Somatic pain- arises
from bone, joint,
muscle, skin or
connective tissue
 Visceral pain
 Tumor involvement
that causes aching and
is fairly well-localized
 Obstruction causes
intermittent cramping
and poor localized
 Abnormal processing by
peripheral or central
nervous system.
 Responds to adjuvant
analgesics.
 Centrally Generated Pain
 Peripherally Generated
Pain Pain felt along entire
nerve pathways.
 Peripheral nerve injurypain felt partially along
the damaged nerve
Acute VS. Chronic Pain
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ACUTE
Sudden
Short Duration < 3
months
Mild--> Severe
Can identify specific
cause.
Predictable prognosis
Can be single event
or recurrent.
 as healing
progresses.
CHRONIC
 Continues for more than one
month after healing or an
acute lesion, or
 Recurs over a chronic period
of time.
 Pathophysiology may be
unclear.
 Unpredictable prognosis
 Is associated with a lesion
that is not expected to heal.
 Chronic cancer pain or
chronic non-malignant pain.
Sources of Pain
Visceral Pain
Muscloskeletal
Neuropathic
Generalized pain
related to visceral
stretch. Described as
sharp ache.
Usually localized.
Irritation of verve.
Described as dull ache. Described as burning,
sharp, shooting.
Classic referral pain.
PT, massage, heat &
cold helpful.
PT helpful.
Responds best to
opioids.
Some response
w/opioids. Adjuvants
helpful.
NSAID’s/Steroids,
muscle relaxers
Opioids usually not
helpful- only dull the
pain. Adjuvants helpful
Tricyclic AD, anticonvulsants.
Acute VS.
Chronic Pain Cont’
 May be associated
with sympathetic  May be associated
with depressed
hyperactivity and
mood, sleep
anxiety.
disturbance and
 Usually resolves
disability.
 Treated with short Treated with longacting drugs.
acting drugs and
adjuvant therapy.
Pharmacology of Pain
Management
 Individualized- Based on the patient’s
medical and pain histories.
 Multi-modal- Targets multiple sites of
action.
 Optimize effects
 Minimize adverse effects
Pharmacology of Pain
Management Cont’
 Routes of Administration
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Oral
Sublingual
Transmucosal (Actiq)
Transdermal (Fentanyl duragesic patch)
Parenteral: IV, IM, SQ
Nebulized
Rectal
Epidural/Intrathecal (Morphine, Fentanyl)
Pharmacology of Pain
Management Cont’
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How do Opioids work?
 Opioids act on the opioid receptor sites and activate
endogenous pain suppression systems in the CNS
(Mu receptor sites).
 Receptor sites are found in:
 Dorsal horn of the spinal cord
 Pituitary gland
 GI tract
 Endogenous & exogenous opioids control pain by
locking onto opioid receptor sites and blocking the
release of neurotransmitters.
Pharmacology of Pain
Management Cont’
 How NSAID’s and Acetaminophen work?
 Non-opioids include NSAID’s, Tylenol and Aspirin.
 They act on the peripheral nerve endings at the
site of injury altering the prostaglandin system.
 NSAID’s have an anti-inflammatory effect.
 Acetaminophen does NOT have an antiinflammatory effect. Like ASA, it has analgesic
and antipyretic effects.
 Side effects:
 NSAID’s: GI irritation, possible
nephrotoxicity.
 Acetaminophen can cause
hepatoxicity.
 Limit 4 grams/24hr
Pharmacology of Pain
Management Cont’
 Short Acting Pain Medications
 Provide analgesia within 30 min.
 Diluadid, Morphine
 Actiq-fastest acting oral medication- onset within
5 min. (transmucosal)
 MSIR oral solution/Roxanol-elixir form of
morphine.
 Helpful for pts. with difficulty swallowing.
 Titratable.
 Oxycodone/MSIR tablets- used for short-term
therapy or supplemental dosing (breakthrough
pain).
 Compounds: Tylenol #3, HydrocodoneLortab/Vicodin, Oxycodone- Percocet.
 Propoxyphene- Darvon/Darvocet
Pharmacology of Pain
Management Cont’
 Long Acting Opioids
 Usually used for long-term pain.
 For patients requiring frequent
breakthrough dosed of opioids.
 More predictable serum levels
 Easier to use; lower dosing intervals,
improved compliance
Comparing Long Acting Opioids
 MSContin/Oxycontin
 8-12 hour duration
 DO NOT CRUSH
TABLETS!!!
 Reassess and titrate
as needed.
 12-24 titration
 Fentanyl/duragesic
Transdermal
 72 H duration
 Convenient
 Reassess and titrate
as needed.
 Effective for patients
with chronic pain and
intolerance to orals.
 Do not cut patch.
 Place above waist and
not on bone.
 24-48 titration
Pharmacology of Pain
Management Cont’
 Meperidine
 Has a metabolite that is 2x as potent as a
convulsant and 1/2 as potent as an analgesic.
 Breaks down to nomeperidine which has an
active metabolite that accumulates w/multiple
dosing.
 Hepatic or renal failure and increases toxicity.
 Accumulation of active metabolites can produce
irritability, tremors, muscle twitching, jerking,
agitation or seizures.
Common Nonopiod Analgesics
Drug
Adult
dose
Considerations
Acetaminophen 650-975 mg
(Tylenol)
q 4 hr
Used for headaches,
osteoarthritis,; lacks peripheral
anti-inflammatory activity of
NSAID’s.
Aspirin
650-975 mg
q 4 hr
Used for headaches,
osteoarthritis, general pain,
antipyretic, inhibits platelet
aggregation.
Ibuprofen
400 mg
q 4-6 hr
Antipyretic, Used for
osteoarthritis, available as liquid
Indomethacin
(Indocin)
150-200
mg/day
Used for gout, antinflammatory,
antirheumatic
Naproxen
(Naprosyn)
500 mg initial
dose, then
250 mg q 6-8
Used for gout, headaches,
smooth muscle contraction,
available in liquid
Adjuvant Analgesics
 Nontraditional analgesics, most
approved for other indications.
 Multipurpose drugs
 For muscloskeletal pain
 Muscle relaxants (Baclofen, Zanaflex)
 For neuropathic pain
 Antidepressants- SSRI’s, TCA’s, SSRI's
(Pamelor, Cymbalta)
 Anticonvulsants- Topamax, Gabapentin,
Lyrica
 Approved for post-herpatic neuralgia, diabetic
neuropathy.
Non-pharmacological Treatments
 Rehabilitative: such at PT/OT
 Psychological
 Interventional
 Nerve blocks
 Trigger point injections
 Complementary therapies
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Acupuncture
Breathing (Lamaze)
Relaxation /Yoga
Meditation
Hypnosis
Massage
Transcutaneous Electrical Nerve
Stimulation (TENS)
Nursing Pain Assessment
 Subjective Assessment
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“I have pain….”; Pt. complains of pain.
It is what the client says it is.
Location- Where?
Description- How does it feel?
 Objective Assessment
 Intensity- Rating scale:
 0 =  pain
 10 = worst possible pain
 Duration- When did it start, How long does
it last, Is it continuous or intermittent?
Nursing Pain Assessment
 Objective Assessment cont.’
 Alleviating & contributing factors
 What makes the pain better or worse?
 Associative factors
 Nausea
 Vomiting
 Altered LOC
 Impact of pain
 How does it affect their lives?
 Past/Pertinent medical hx
 Past pain experiences
 Recent surgery, chemical use or abuse
Nursing Pain Assessment
 Objective Assessment cont.’
 Vital Signs
 Face
 Facial grimace
 Clenched jaw
 Muscle tone
 Relaxed
 Rigid
 Vocalization
 Moaning, crying, grunting, whimpering
Nursing Diagnosis
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Alteration in Comfort
Impaired Gas Exchange
Alteration in Cardiac Output
Potential for Ineffective Airway Clearance
Anxiety
Impaired Physical Mobility
Ineffective Coping
Potential for Infection
Altered Bowel Elimination
Planning, Goal Setting &
Interventions
 Alleviate Pain!!!!!!!! Improve Comfort.
 By when?
 From what to what? 0-10
 Interventions
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Pain Medication!!
Adjuvants
Positioning
Responsibility
Involve Family
Humor
 Preventing Complications!!!!!!
Important Definitions
 Tolerance- an adaptive process due to exposure to
a drug over time. Results in a decrease response to
a drug’s effect over time.
 Physical Dependence- a physiologic
phenomenon that should be expected in persons with
persistent use of certain drugs. Patients will
experience a withdrawal syndrome if a drug is
abruptly stopped, there is a rapid dose reduction, or if
the person is given a reversal agent. Withdrawal can
be prevented by gradual taper
 Reversal Agents
 Narcan- Opioids
 Romazacon- Benzodiazapam
Important
Definitions Cont.’
 Pseudoaddiction- This is not true
addiction and is created by under
treatment of pain. A term used to
describe behaviors seen in persons who
fear or who are experiencing
uncontrolled pain and want to obtain
medication for adequate pain relief.
The “clock-watching”, requesting extra
opioids, and demanding behaviors are
eliminated when the pain is relieved.
Important
Definitions Cont.’
 Addiction- A primary, chronic,
neurobiological disease with genetic,
psychosocial and environmental factors.
Characteristics include:
 Impaired control over drug use
 Compulsive use
 Continued use despite harm
 The need to use an opioid for effects other than
for pain relief and craving.
Important Definitions Cont.’
 Breakthrough Pain Transitory increase in pain to greater than
moderate intensity which occurs on top of
the baseline pain.
 Distinguished from:
 Continuous or uncontrolled pain
 Acute episodic pain.
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Portenoy RK, Hagen NA. Pain, 1990;41:273-281
Breakthrough Pain
 50% of all inpatients are under treated.
 Types
 Incident
 Idiopathic/spontaneous
 End-of-dose failure
 Characteristics
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Moderate-to-severe intensity
Rapid onset
Often unpredictable
Short duration
3-4 episodes per day
Associated with a more severe pain syndrome
IMPAIRMENT OF QUALITY OF LIFE!!!
Pain: Gerontologic Considerations
 45-80% of older adults have chronic pain.
 Inadequately assessed and treated.
 Common types: osteoarthritis, low back pain
and previous fracture sites.
 Chronic pain can lead to :
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Depression
Sleep disturbances
Decreased mobility
Increased health care utilization $$$$
Physical & social role dysfunction
Ethical Issues in Pain
Management
 Requests for Assisted Suicide
 Only legal in Oregon.
 Use of Placebos
 How do you feel about them?
 Check institutions policy.
 Cognitively impaired individuals
 Patients with substance abuse
problems
Pain: Gerontologic Considerations
Cont.’
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Believe that pain is “normal”.
Nothing can be done.
Labeled as “burdensome” or “bad pt.”
Fear of drugs.
Pain tolerance DECREASES with age.
Cognitive, sensory-perceptual , and
motor problems may impair ability to
communicate or process information.
 Post-stroke aphasia, paraplegia, dementia,
delirium, vision, hearing impairments
The Effect of Pain on the Body
SYSTEM
Endocrine
RESPONSES
Adrenocorticotropic Hormone(ACTH),
cortisol, antidiuretic hormone (ADH),
epinephrine, norepinephrine, renin,
aldosterone, insulin, testosterone
Metabolic
Gluconeogenesis, glyconeolysis,
hyperglycemia, glucose intolerance, insulin
resistance, muscle protein catabolism,
lipolysis
Cardiovascular
heart rate, cardiac output, peripheral
vascular resistance, hypertension, myocardial
02 consumption, and coagulation
Respiratory
Tidal volume & cough, atelectasis, shunting,
hypoxemia, sputum retention, infection
The Effect of Pain on the Body
Cont.’
Genitourinary
Urinary output, urinary retention
Gastrointestinal
Gastric and bowel motility
Musculoskeletal
Muscle spasm, impaired muscle
function, fatigue, immobility
Neurologic
Reduction in cognitive functions,
mental confusion
Immunologic
Immune response
Myofascial Pain Syndrome
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Soft Tissue Pain (Somatic)
Specific to one regional area of the body
Pressure or strain causes the pain to travel.
Cause thought to be related to muscle
trauma or chronically strained muscles.
 Pain originates within the fascia of skeletal
muscles.
 Deep aching pain accompanied by:
 “Burning, stinging, and stiffness”
Fibromyalgia
Syndrome
 Widespread, nonarticular muscloskeletal pain
and fatigue with multiple tender points.
 Non-degenerative, non-progressive & noninflammatory.
 Effects over 6 million Americans
 More women than men; 20-55 years old.
 Possible causes;
 Abnormal levels of serotonin, norepi and other
neurotransmitters.
 Hyperfunctioning of the hypothalamic-pituitaryadrenal axis (HPA).
Fibromyalgia Syndrome
Treatment
 Supportive management
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NSAID’s
Tricyclic Anti-depressants or SSRI’s
Well balanced diet
Behavioral Therapy
Financial concerns and support
Carefully graduated exercise program.
Chronic Fatigue Syndrome
 Disorder characterized by debilitating fatigue
and a variety of associated complaints.
 3x more likely in women; onset 25-45 years
old.
 Etiology unknown
 Ideas:
 Viral infection usually precipitates the
syndrome.
 Abnormal immune function.
 Alterations in the CNS.
 Possible dysfunction of the HPA axis.
 Depression usually occurs in patients.
Nursing Care of the
Client with Cancer
End-of-Life Care
Nursing Care of the Client
with Cancer
 Cancer Background
A. Definition
 1. Family of complex diseases
 2. Affect different organs and organ systems
 3. Normal cells mutate into abnormal cells that take
over tissue
 4. Eventually harm and destroy host
 5. Historically, cancer is a dreaded disease
B. Oncology
 1. Study of cancers
 2. Oncology nurses specialize in
the care, treatment of clients with cancer
Nursing Care of the Client
with Cancer
 Incidence and Prevalence
 1. Cancer accounts for about 25% of
death on yearly basis
 2. Males: 3 most common types of
cancer are prostate, lung and bronchial,
colorectal
 3. Females: 3 most common types of
cancer are breast, lung and bronchial,
and colorectal
Nursing Care of the Client
with
Cancer
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Risk factors for cancer: (some are controllable; some are not)
 1. Heredity: 5 – 10% of cancers; documented with some breast and
colon cancers
 2. Age: 70% of all cancers occur in persons > 65
 3. Lower socio-economic status
 4. Stress
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Leads to greater wear and tear on body in general
5
Diet: certain preservatives in pickled, salted foods; fried foods;
high-fat, low fiber foods; charred foods, high fat foods, diet high in
red meat
6. Occupational risk: exposure to know carcinogens, radiation,
high stress
7. Infections, especially specific organisms and organ (e.g.
papillomavirus causing genital warts and leading to cervical cancer)
8. Tobacco Use: Lung, oral and laryngeal, esophageal, gastric,
pancreatic, bladder cancers
9. Alcohol Use: also tied with smoking
10. Sun Exposure (radiation) e.g. skin cancer
Nursing Care of the Client
with Cancer
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Nursing role includes health promotion to lower the
controllable risks
1. Routine medical check up and screenings
2. Client awareness to act if symptoms of cancer occur
3. Screening examination recommendations by American
Cancer Society; specifics are made according to age and
frequencies
 a. Breast Cancer: self-breast exam, breast examination
by health care professionals, screening mammogram
 b. Colon and Rectal Cancer: fecal occult blood, flexible
sigmoidoscopy, colonoscopy
 c. Cervical, Uterine Cancer: Papanicolaou (Pap) test
 d. Prostate Cancer: digital rectal exam, Prostate-specific
antigen (PSA) test
Nursing Care of the Client
with Cancer
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Physiology of Cancer
A. Background
1. Normal Cell Growth includes two
events
 a. Replication of cellular DNA
 b. Mitosis (cell division)
Nursing Care of the Client
with Cancer
 2. Cell cycle is under control of cyclins,
and suppresor gene products which control
process by working with enzymes;
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cyclins promote cell division
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suppresor gene products limit cell
division
 3. Forms the basis of how some
chemotherapeutic agents work against
cancers
Nursing Care of the Client
with Cancer
 Theories of Carcinogenesis (what causes cancer to
occur)
1. Cellular Mutation
 a. Cells begin to mutate (change the DNA to unnatural
cell reproduction)
2. Oncogenes/Tumor Suppressor Genes Abnormalities
 a. Oncogenes are genes that promote cell proliferation
and can trigger cancer
 b. Tumor suppressor genes normally suppress
oncogenes but are damaged
3. Exposure to Known Carcinogens
 a. Act by directly altering the cellular DNA (genotoxic)
 b. Act by affecting the immune system (promotional)
Nursing Care of the Client
with Cancer
4.
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5.
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Viruses
viruses break the DNA chain and mutates the
normal cells DNA
Epstein-Barr virus
Human papilloma virus
Hepatitis virus
Drugs and Hormones
a. Sex hormones often affect cancers of the
reproductive systems (estrogen in some breast
cancers; testosterone in prostate cancer)
b. Glucocorticoids and steroids alter immune
system
6.
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Chemical Agents
a. Industrial and chemical
b. Can initiate and promote cancer
b. Examples: hydrocarbons in soot ; arsenic in
pesticides; chemicals in tobacco
7. Physical Agents
 a. Exposure to radiation
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Ionizing radiation found in x-rays, radium, uranium
UV radiation
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Sun, tanning beds
8. Immune function
1. Protects the body from cancerous cells
2. Increased rate of cancer in immunocompromised pts
Nursing Care of the Client
with Cancer
 Neoplasms: also called tumors (mass of new tissue that grows
independently of surrounding organs
1. Types of neoplasms
a. Benign
 1. Localized growths respond to body’s homeostatic controls
 2. Encapsulated
 3. Stop growing when they meet a boundary of another
tissue
 4. Can be destructive
b. Malignant
 1. Have aggressive growth, rapid cell division outside the
normal cell cycle
 2. Not under body’s homeostatic controls
 3. Cut through surrounding tissues causing bleeding,
inflammation, necrosis (death) of tissue
Nursing Care of the Client
with Cancer
 Malignant tumors can metastasize
a. Tumor cells travel through blood or lymph
circulation to other body areas and invade tissues
and organs there.
 1. Primary tumor: the original site of the
malignancy
 2. Secondary tumor (sites): areas where
malignancy has spread i.e. metastasis (metastatic
tumor)
 3. Common sites of metastasis are lymph nodes,
liver, lungs, bones, brain
 4. 50 – 60 % of tumors have metastasized by time
primary tumor identified
b. Cancerous cells must avoid detection by immune
system
Nursing Care of the Client
with Cancer
C. Malignant neoplasms can recur after surgical removal of primary
and secondary tumors and other treatments
D. Malignant neoplasms vary in differentiation.
 a. Highly differentiated are more like the originating
tissue
 b. Undifferentiated neoplasms consist of immature
cells with no resemblance to parent tissue and have no
useful function
E. Malignant cells progress in deviation with each
generation and do no stop growing and die, as do
normal cells
F. Malignant cells are irreversible, i.e. do not revert to
normal
G.Malignant cells promote their own survival by hormone
production, cause vascular permeability; angiogenesis;
divert nutrition from host cells
The steps of metastasis
Nursing Care of the Client
with Cancer
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Effects of Cancer
1. Disturbed or loss of physiologic functioning, from pressure
or obstruction
 a. Anoxia and necrosis of organs
 b. Loss of function: bowel or bladder obstruction
 c. Increased intracranial pressure
 d. Interrupted vascular/venous blockage
 e. Ascites
 f. Disturbed liver functioning
 G. Motor and sensory deficits
 Cancer invades bone, brain or compresses nerves
h. Respiratory difficulties
a. Airway obstruction
b. Decreased lung capacity
Nursing Care of the Client
with Cancer
2. Hematologic Alterations: Impaired function of blood cells
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4.
5.
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Secondary to any cancer that invades the bone marrow (leukemia)
May also be caused by the treatment
a. Abnormal wbc’s: impaired immunity
b. Diminished rbc’s and platelets: anemia and clotting
disorders
Infections: fistula development and tumors may become
necrotic; erode skin surface
Hemorrhage: tumor erosion, bleeding, severe anemia
Anorexia-Cachexia Syndrome: wasting away of client
a. Unexplained rapid weight loss, anorexia with altered smell
and taste
b. Catabolic state: use of body’s tissues and muscle proteins
to support cancer cell growth
Nursing Care of the Client
with Cancer
6. Paraneoplastic Syndromes: ectopic sites with excess hormone
production
 a. Parathyroid hormone (hypercalcemia)
 b. Ectopic secretion of insulin (hypoglycemia)
 c. Antidiuretic hormone (ADH: fluid retention)
 d. Adrenocorticotropic hormone (ACTH)
7. Pain: major concern of clients and families
a. Types of cancer pain
 1. Acute: symptom that led to diagnosis
 2. Chronic: may be related to treatment or to progression of
disease
b. Causes of pain
 1. Direct tumor involvement including metastatic pain
 2. Nerve compression
 3. Involvement of visceral organs
Nursing Care of the Client
with Cancer
8. Physical Stress: body tries to respond and destroy
neoplasm
 a. Fatigue
 b. Weight loss
 c. Anemia
 d. Dehydration
 e. Electrolyte imbalances
9. Psychological Stress
 a. Cancer equals death sentence
 b. Guilt from poor health habits
 c. Fear of pain, suffering, death
 d. Stigmatized
Nursing Care of the Client
with Cancer

A.
1.






2.
Collaborative Care
Diagnostic Tests: used to diagnose cancer
Determine location of cancer
a. Xrays
b. Computed tomography
c. Ultrasounds
d. Magnetic resonance imaging
e. Nuclear imaging
f.
Angiography
Diagnosis of cellular type of can be done through tissue
samples from biopsies, shedded cells (e.g. Papanicolaou
smear) washings
 a. Cytologic Examination: tissue examined under
microscope
 b. Identification System of Tumors: Classification – Grading - Staging
Nursing Care of the Client
with Cancer
1. Classification: according to the tissue or
cell of origin, e.g. sarcoma, from supportive
2. Grading:
 a. Evaluates degree of differentiation and
rate of growth
 b. Grade 1 (least aggressive) to Grade 4
(most aggressive)
3. Staging
 a. Relative tumor size and extent of
disease
 b. TNM (Tumor size; Nodes: lymph node
involvement; Metastases)
Nursing Care of the Client
with Cancer
3. Tumor markers: specific proteins which indicate
malignancy
 a. PSA (Prostatic-specific antigen): prostate
cancer
 b. CEA (Carcinoembryonic antigen): colon cancer
 c. Alkaline Phosphatase: bone metastasis
4 Direct Visualization
 a. Sigmoidoscopy
 b. Cystoscopy
 c. Endoscopy
 d. Bronchoscopy
 e. Exploratory surgery; lymph node biopsies to
determine metastases
Nursing Care of the Client
with Cancer
Other non-specific tests
 a. CBC, Differential
 b. Electrolytes
 c. Blood Chemistries: (liver enzymes:
alanine aminotransferase (ALT);
aspartate aminotransferase (AST) lactic
dehydrogenase (LDH)
Nursing Care of the Client
with Cancer
Treatment Goals: depending on type and stage of cancer
A. Cure
 1. Recover from specific cancer with treatment
 2. Alert for reoccurrence
 3. May involve rehabilitation with physical and
occupational therapy
B. Control: of symptoms and progression of cancer
 1. Continued surveillance
 2. Treatment when indicated (e.g. some bladder
cancer, prostate cancer)
C. Palliation of symptoms: may involve terminal care if
client’s cancer is not responding to treatment
Nursing Care of the Client
with Cancer
Treatment Options (depend on type of cancer)
alone or with combination
A.
Chemotherapy
 1. Effects are systemic and kills the
metastatic cells
 2. Often combinations of drugs in specific
protocols over varying time periods
 Much more effective then a single agent
 Consider the timing of the nadir of each drug
 The time when the bone marrow activity and WBC
counts are at their lowest levels after chemo
 Different times for different drugs
 3. Cell-kill hypothesis: with each cell
cycle a percentage of cancerous cells
are killed but some remain; repeating
chemo kills more cells until those left
can be handled by body’s immune
system
Nursing Care of the Client
with Cancer
B.
1.


2.

Classes of Chemotherapy Drugs
Alkylating agents
1. Action: create defects in tumor DNA
2. Examples: Nitrogen Mustard, Cisplatin
Antimetabolites
1. Action: similar to metabolites needed for vital cell
processes
 Counterfeit metabolites interfere with cell division
 2. Examples: Methotrexate; 5 fluorouracil
 3. Toxic Effects: nausea, vomiting, stomatitis, diarrhea,
alopecia, leukopenia
3. Antitumor Antibiotics
 1. Action: interfere with DNA
 2. Examples: Actinomycin D, Bleomycin
 3. Toxic Effect: damage to cardiac muscle
Nursing Care of the Client
with Cancer
4. Antimiotic agents
 1. Action: Prevent cell division
 2. Examples: Vincristine, Vinblastine
 3. Toxic Effects: affects neurotransmission,
alopecia, bone marrow depression
5. Hormone agonist
 1. Action: large amounts of hormones upset the
balance and alter the uptake of other hormones
necessary for cell division
 2. Example: estrogen, progestin, androgen
6. Hormone Antagonist
 1. Action: block hormones on hormonebinding tumors (breast, prostate,
endometrium; cause tumor regression
 Decreasing the amount of hormones can
decrease the cancer growth rate
 Does not cure, but increases survival rates
 2. Examples: Tamoxifen (breast);
Flutamide (prostate)
 3. Toxic Effects: altered secondary sex
characteristics
 7. Hormone inhibitors
 Aromatase inhibitors (Arimidex,
Aromasin)
 Prevents production of aromatase which is
needed for estrogen production
 Used in post menopausal women
 Side effects
 Masculinizing effects in women
 Fluid retention
Nursing Care of the Client
with Cancer
Effects of Chemotherapy
 a. Tissues (fast growing) frequently affected
 b. Examples: mucous membranes, hair cells, bone marrow,
specific organs with specific agents, reproductive organs (all
fetal toxic, impair ability to reproduce).
Administration of chemotherapeutic agents
a. Trained and certified personnel, according to established
guidelines
b. Preparation
 1. Protect personnel from toxic effects
 Drugs absorbed through skin and mucous membranes
 Protective clothing and extreme care
 2. Extreme care for correct dosage; double check with
physician orders, pharmacist’s preparation
c. Proper management clients’ excrement
Nursing Care of the Client
with Cancer
d. Routes
 1.
Oral
 2.
Body cavity (intraperitoneal or
intrapleural)
 3.
Intravenous
a. Use of vascular access devices
because of threat of extravasation
(leakage into tissues) and long-term
therapy
a. If the drug is a vessicant it may result in
pain, infection and tissue loss
e.Types of vascular access devices
 1. PICC lines (peripherally inserted
central catheters)
 2. Tunnelled catheters (Hickman,
Groshong)
 3. Surgically implanted ports
(accessed with 90o angle needle
Hickman Catheter
Portacath
PICC Line
Nursing Care of the Client
with Cancer
Managing side effects of chemotherapy
 A. Nausea and vomiting
 80% of patients will develop it
 Antiemetics such as Zofran, Tigan,
Compazine as well as Ativan to control
the symptoms
 Monitor for dehydration and need for IV
fluids
 B. Bone marrow suppression
 Decreased number of RBC
 Leads to hypoxia, fatigue
 Hgb 9.5-10 gm/dl require oral iron
supplements
 Hgb below 8 gm/dl require transfusion
 May use Epogen to stimulate RBC production

Decrease number of WBC (normal 4,500-11,000
mm3) especially neutrophils (normal 3,000-7,000
cells/cc)
 Neutropenia-count below 2000
 Pt at extreme risk for infection
 May order granulocyte colony stimulating factor
(leukine) to stimulate bone marrow to increase WBC
count
 Neutropenic precautions






Private room
Good handwashing
Monitor temp q 4 hours, monitor for chills, UTI, pneumonia
Limit visitors to healthy adults
No flowers or plants
Monitor neutrophil count

Thrombocytopenia
 Drop in platlet count (normal 150,000400,000/mm3) below 100,000
 Test pt for bleeding in stool and urine
 Avoid punctures for IV or IM
 Handle pt gently
 Use electric razor
 Avoid placing foley or rectal thermometers
 Avoid oral trauma with soft bristle brushes,
avoid flossing, avoid hard candy
 Watch for ALOC, pupil changes that might
indicate intracranial bleeds
 Stool softeners to avoid straining
C. Mucocitis
 Inflammation and ulceration of mucous
membranes and entire GI tract
 Rinse mouth with ½ normal saline and ½
peroxide every 12 hours
 Topical analgesic medication
 Avoid mouthwashes with alcohol
 Avoid spicy or hard food
 Watch nutritional status
D. Alopecia
 Hair loss
 2-3 weeks after treatment is started
 Affects all the hair, including eyebrows,
eyelashes
 Within 4-8 weeks after treatment hair
begins to grow back
 Before hair loss, have the pt pick out a
wig that is similar to hair color
E. Peripheral neuropathy
 Numbness and tingling to fingers and
toes in a glove and sock pattern
 May cause gait and possible fall
problems
F. Provide emotional and spiritual
support to patient and families
Nursing Care of the Client
with Cancer






Surgery
1. Diagnosis, staging, and sometimes treatment of cancer
2. May be prophylaxis or removal of at risk tissue or organ
prior to development of cancer (breast cancer)
3. Involves removal of body part, organ, sometimes with
altered functioning (e.g. colostomy)
4. Debulking (decrease size of) tumors in advanced cases
5. Reconstruction and rehabilitation (e.g. breast implant
post mastectomy)
6. Palliative surgery to improve the quality of life
 Removal of tumor tissue that is causing pain or obstruction
 5. Psychological support to deal with surgery as well as
cancer diagnosis
Nursing Care of the Client
with Cancer
Radiation Therapy
1. Treatment of choice for some tumors to kill or
reduce tumor, relieve pain or obstruction


2. Delivery
a. Teletherapy (external): radiation delivered in
uniform dose to tumor



Beam radiation
b. Brachytherapy: delivers high dose to tumor and
less to other tissues; radiation source is placed in
tumor or next to it in the form of seeds


Destroy cancer cells with minimal exposure to normal
cells
Cells die or are unable to divide
Radiation source within the patient so pt emits radiation
for a period of time and is a hazard to others
c. Combination
3. Goals
 a. Maximum tumor control with minimal
damage to normal tissues
 b. Caregivers must protect selves by using
shields, distancing and limiting time with
client, following safety protocols
 Private room
 Caution sign on the door for radioactive
material
 Dosimeter film badge by staff
 No pregnant staff
 Limit visitors to ½ hour per day and keep them
at least 6 ft from the source
Nursing Care of the Client
with Cancer
4. Treatment Schedules
 a. Planned according to radiosensitivity of tumor,
tolerance of client
 b. Monitor blood cell counts
5. Side Effects
 a. Skin (external radiation): blanching, erythema,
sloughing, breakdown
 Use mild soak
 Dry skin with a patting motion, not rubbing
 Don’t use powders or lotions unless prescribed by
radiologist
 Wear soft clothing over the site
 Avoid the sun and heat
 b. Ulcerated mucous membranes: pain,
lack of saliva (xerostoma)
 c. Gastrointestinal: nausea and vomiting,
diarrhea, bleeding, sometimes fistula
formation
 d. Radiation pneumonitis
 1-3 months after treatment
 Cough, SOB, fever
 Treated with steroids to decrease
inflammation
Nursing Care of the Client
with Cancer
Monoclonal antibodies (inoculate
animal with tumor antigen and retrieve
antibodies against tumor for human)
 Antibodies target specific substances
needed by the cancer cell for growth
(Herceptin for breast cancer)
Gene therapy
 experimental
 May insert gene into the tumor cells to
make them more susceptible to being
killed by antiviral agents
 May insert genes for cytokines that
increase their effectiveness in killing
cancer cells
Angiogenesis inhibitor drugs

prevent new blood vessels from
forming and delivering blood to the
tissue
Nursing Care of the Client
with Cancer
F. Bone Marrow Transplantation and Peripheral Blood Stem Cell
Transplantation
 1. Stimulation of nonfunctioning marrow or replace bone marrow
 2. Common treatment for leukemias
G. Pain Control
 1. Includes pain directly from cancer, treatment, or unrelated
 2. Necessary for continuing function or comfort in terminally ill
clients
 3. Goal is maximum relief with minimal side effects
 4. Multiple combinations of analgesics (narcotic and nonnarcotic) and adjuvants such as steroids or antidepressants;
includes around the clock (ATC) schedule with additional
medications for break-through pain
 5. Multiple routes of medications
 6. May involve injections of anesthetics into nerve, surgical
severing of nerves radiation
 7. May need to progress to stronger pain medications as pain
increases and client develops tolerance to pain medication
Nursing Care of the Client
with Cancer

Nursing Diagnoses for Clients with Cancer
A. Anxiety
 1. Therapeutic interactions with client and family; community
resources such as American Cancer Society, “I Can Cope”
 2. Availability of community resources for terminally ill (Hospice
care in-patient, home care)
B. Disturbed Body Image
 1. Includes loss of body parts (e.g. amputations); appearance
changes (skin, hair); altered functions (e.g. colostomy); cachexic
appearance, loss of energy, ability to be productive
 2. Fear of rejection, stigma
C. Anticipatory Grieving
 1. Facing death and making preparations for death: will be
consideration
 2. Offer realistic hope that cancer treatment may be successful
Nursing Care of the Client
with Cancer
D. Risk for Infection
E. Risk for Injury
 1. Organ obstruction
 2. Pathological fractures
F. Altered Nutrition: less than body requirements
 1. Consultation with dietician, lab evaluation of nutritional
status
 2. Managing problems with eating: anorexia, nausea and
vomiting
 3. May involve use of parenteral nutrition
G. Impaired Tissue Integrity
 1. Oral, pharyngeal, esophageal tissues (due to chemotherapy,
bleeding due to low platelet counts, fungal infections such as
thrush)
 2. Teach inspection, frequent oral hygiene, specific nonirritating products, thrush control
Nursing Care of the Client
with Cancer
Oncologic Emergencies
A. Pericaridal Effusion and Neoplastic
Cardiac Tamponade
 1. Concern: compression of heart by fluid
in pericardial sac, compromised cardiac
output
 2. Treatment: pericardiocentesis
B.
Superior Vena Cava Syndrome
 1. obstruction of venous system with
increased venous pressure and stasis;
facial and neck edema with slow
progression to respiration distress
 Late signs are cyanosis, decreased cardiac
output and hypotension
 2. Treatment: respiratory support;
decrease tumor size with radiation or
chemotherapy
Compression of the superior vena cava in SVC
syndrome
C. Sepsis and Septic Shock
 1. Early recognition of infection
 Patients at risk secondary to low WBC
and impaired immune system
 2. Treatment: prompt intervention
with antibiotics and vasopressors
 D. DIC disseminated
intravascular coagulation
 Triggered by severe illness, usually
sepsis in cancer patients
 Abnormal clotting uses up existing
clotting factors and platelets quickly then
the pt hemorrhages
 Mortality rate is 70%
 Prevention of sepsis is key
Nursing Care of the Client
with Cancer
E. Spinal Cord Compression
 1. Pressure from expanding tumor or
vertebral collapse can cause irreversible
paraplegia
 2. Back pain initial symptom with
progressive paresthesia and paralysis
 Paralysis is usually permanent
 3. Treatment: early detection
 High dose corticosteroid to decrease the swelling
 radiation or surgical decompression
F.Obstructive Uropathy
 1. Concern: blockage of urine flow;
undiagnosed can result in renal failure
 2. Treatment: restore urine flow
G.Hypercalcemia
 1. High calcium (normal 9-10.5) usually from bone
metastases
 2. May also come from cancer of the lung, head,
neck, kidney and lymph nodes that secrete
parathyroid hormone that causes the bone to
release calcium
 2. Symptoms include fatigue, muscle weakness,
polyuria, constipation, progressing to coma,
seizures
 3. Treatment
 restore fluids with intravenous saline which also
increases the excretion of calcium
 loop diuretics increase calcium excretion
 Calcium chelators such as mithracin
 Inhibit calcium resorption from the bone with calcitonin,
diphosphonate
H.
Tumor Lysis Syndrome
 1. Occurs with rapid necrosis of tumor cells
with chemotherapy
 When tumor cells die they release potassium
and purines
 Potassium (norm 3.5-5.5) elevation causes
cardiac arrhthymias, muscle weakness,
twitching, cramps
 Purines convert to uric acid which causes
renal failure, flank pain, gout when elevated
above 10 mg/dl
 Hyperphosphatemia with secondary to
hypocalcemia causes heart block, HTN, renal
failure
 Treatment
 Hydration
 Instruct pt to increase fluid intake before
and after chemo
 May need IV hydration
 Diuretics to increase urine flow
 Allopurinol to increase uric acid
excretion
 May need dialysis
Nursing Care of the Client
with Cancer
I. SIADH (Syndrome of Inappropriate Antidiuretic Hormone
Secretion)
 1. Ectopic ADH production from tumor leads to excessive
hyponatremia
 2. holds onto too much fluid which decreases sodium level
(normal 135-145)
 3. Symptoms
 Weakness, muscle cramps, fatigue, ALOC, headache, seizures
 2.
Treatment: restore sodium level
 Fluid restriction
 Increase sodium
 Antibiotic demeclocycline works in opposition to ADH
 Limits ADH effect on distal renal tubules so they can excrete water