Transcript MS1 Ch 8 Patient with Cancer

Medical-Surgical Nursing:
Concepts & Practice
3rd edition
Chapter 8
Care of Patients with Cancer
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Theory Objectives
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Analyze organization of neoplastic (abnormal
tissue) growth.
Identify at least five factors that may contribute to
the development of a malignancy.
List at least four practices that can contribute to
prevention and early detection of cancers.
Include the recommendations of the American
Cancer Society (ACS) for routine checkups and
detection of cancers into patient education.
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Theory Objectives (Cont.)
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Explain the advantages and disadvantages of
the various treatments available for cancer.
Illustrate the major problems for a patient who
is coping with side effects of radiation or
chemotherapy for cancer and state the
appropriate nursing interventions.
Apply knowledge of the stages of the grieving
process experienced by the dying cancer to
patient’s coping level.
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3
Clinical Practice Objectives
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Devise an individual plan of care for the patient
receiving chemotherapy.
Formulate a teaching plan for the patient who has
bone marrow suppression from cancer treatment.
Institute nursing interventions to help the patient cope
with the common problems of cancer and its
treatment.
Use appropriate nursing interventions to help patients
and families deal with the psychosocial effects of
cancer and its treatment.
Employ nursing interventions to help the cancer
patient cope with death and dying.
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4
Impact of Cancer
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Cancer is a group of diseases that
characteristically grow in an uncontrolled
manner with the spread of abnormal cells.
If all of the cancers that are detectable early
were diagnosed in localized stages, the 5year survival rate would be 95%.
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5
Physiology of Cancer
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Neoplasm
Benign neoplasm
Malignant neoplasm
Metastasis
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Neoplasm
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An abnormal replication of cells
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Benign Neoplasm
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Neoplasm that is usually harmless
Almost always encapsulated (surrounded by
a fibrous capsule)
The capsule prevents the release of cells and
restricts their spread to other parts of the
body.
Can create problems if they press against
and interfere with the normal structure and
function of nearby organs
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8
Malignant Neoplasm
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Changes a cell’s DNA makeup and function
Cancer cells do not look or behave like
normal cells.
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The nuclei of malignant (cancer) cells are large
and irregular.
They fail to follow the rules that regulate the
reproduction of normal cells.
They do not seem to “know” when to stop
multiplying.
The offspring of cancerous cells proliferate
(multiply) in great numbers.
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Malignant Neoplasm (Cont.)
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They grow increasingly disorganized, often
forming tumor masses.
Some cancerous cells take on new characteristics
so that they do not in any way resemble the cells
of the original tissue.
The malignant cells invade neighboring tissues
and travel to other parts of the body; there they
establish another colony of malignant cells.
Their demand for nutrients depletes the supply of
nourishment available for normal cells.
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10
Normal and Malignant
Skeletal Muscle Cells
From McCance KL, Huether SE, Brashers VL, Rote ND:
Pathophysiology: The biologic basis for disease in adults and
children, ed. 6, Philadelphia, 2010, Elsevier.
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11
Classification of Tumors
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Tumors are classified according to the
substances they are formed from
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“-oma”—swelling
“-sarcoma”—mesenchymal origin
“-carcinoma”—epithelial origin
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12
Metastasis
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Movement of cancer cells from the original
cancer site to other areas of the body
Not all malignant cells metastasize, but the
great majority of malignant cells do.
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13
Modes of Dissemination of Cancer
From Monahan FD, Neighbors M, Sands M, et al: Medicalsurgical nursing: Health and illness perspective, ed. 8, St. Louis,
2007, Mosby.
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14
Prognosis
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Prognosis depends on how much the
malignant cells have attacked body tissues
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In Situ
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Localized growth that remains at the original site
and has not yet released its cells even though the
growth may have invaded underlying tissues
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Localized
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All of the malignant cells are in the area where
the new growth started.
At this stage, the disease is much more easily
destroyed.
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Regional Malignancy
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Cells from the original malignancy have spread to
the body area right around the tumor, such as to
nearby lymph nodes.
The spread has been limited, however, by the
body’s protective mechanisms.
Cells may continue to grow and multiply.
If the regional cancer is not successfully treated,
malignant cells will eventually break away and
spread throughout the body.
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TNM Staging System
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T—primary tumor
N—regional nodes
M—metastasis
The number written beside each letter indicates
how much the malignancy has spread and attacked
other tissues.
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TNM Staging System (Cont.)
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T1, N0, M0 means that the tumor is small and
localized (no involvement of regional lymph
nodes and no metastasis).
T1, N2, M1 indicates a small (T1) tumor with
moderate regional involvement (N2) that has
metastasized to one distant site or organ
(M1).
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20
Causative Factors
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All cancer results from defects in the DNA of
genes.
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Can be inherited or caused by mutation
Oncogenes and tumor suppressor genes
Immunocompetence
Carcinogens in external and internal
environment
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Mutation
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Permanent change in the DNA sequence of a
gene
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Oncogenes
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Cancer-causing genes
Mistakes in the instructions inside a cell’s
DNA genetic code, whereby newly created
cells are no longer normal
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The defective gene tells the new cells to multiply
at a higher rate.
The defective coding prevents the newly created
defective cells from dying and being reabsorbed.
Results in a tumor, or mass
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Tumor Suppressor Genes
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Healthy, normal genes that control the growth
of cells in the body
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Immunocompetence
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The capability of one’s immune system to
deal with foreign cells
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Bacterial
Viral
Malignant
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Chemical Carcinogens
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Cancer-causing substances
Carcinogens in the external environment
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Certain chemicals
Sources of radiation
Viruses
Carcinogens in the internal environment
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Hormones
Inherited genes
Advanced age
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Occupational Carcinogens
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Petrofluorocarbons (polychlorinated biphenyls
or PCBs)
Some pesticides (e.g., DDT)
Pitch, asphalt, crude paraffin, and petroleum
products
Irritating substances in the air
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Tobacco smoke
Asbestos
Chemical wastes from industry and automobiles
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Occupational Carcinogens (Cont.)
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Soot
Aniline dyes
Vinyl chloride, nickel, arsenic, and chromate
Benzene
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Tobacco
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Cigarette smoking is linked to cancer of the
lung and is thought to be linked to
esophageal, pancreatic, bladder, and kidney
cancers.
Encourage those who smoke to quit.
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Ninety percent of lung cancers in men and 79% in
women are related to smoking.
Use of tobacco in conjunction with the intake of
alcohol is related to several other types of cancer.
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Promoters
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Promoters are not carcinogenic when found
alone, but when they are in the body with a
known carcinogen, cancer occurs faster.
Alcohol is a promoter.
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When nicotine is present, cancers occur at a faster
rate in those who are heavy consumers of alcohol
than in someone who uses nicotine but does not
drink alcohol.
It is thought that about 90% of all head and neck
cancers are tobacco plus alcohol related.
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Promoters (Cont.)
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Chronic irritation
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A contributing cause of cancer
The presence of a mole or exposure to chemical
carcinogen or ultraviolet (UV) rays
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Carcinogenic Drug Therapies
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Immunosuppressive drugs used to suppress
organ transplant rejection are a cause of nonHodgkin’s lymphoma.
Synthetic estrogens are linked to a higher
incidence of endometrial cancer; many of the
drugs used to treat cancer affect the immune
system and can predispose to other types of
cancer.
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Physical Carcinogens: Radiation
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May originate from x-ray machines,
radioactive elements, or UV rays from the sun
Capable of penetrating certain body tissues
and causing the development of malignant
cells in the affected area
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Radiation (Cont.)
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People with fair complexions have less
protective pigment and therefore are more
likely to develop skin cancer from UV
radiation than are people with darker skin.
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Radiation (Cont.)
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There is continued concern about the
dangers that excessive radiation in the
environment presents, especially the longterm effects that are not immediately
apparent but may eventually prove to be
related to malignancy.
In addition to leukemia, cancers of the skin,
bone marrow, breast, lung, and thyroid are
believed to be closely linked to exposure to
radiation.
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Radon Gas
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People who live in areas that have more
radon emission from the earth have a higher
incidence of malignancy in the population
than people in areas that are low in radon.
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Viruses
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Experiments involving animals have
demonstrated that a number of cancers can
be produced in animals by injecting them with
a filtrate from virus-infected malignant
growths.
These viruses are known as oncoviruses
because of their ability to cause cancer.
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Viruses (Cont.)
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Viruses are capable of introducing new genetic
material into a normal cell and transforming it into
a malignant one.
Cell reproduction can be altered when viruses
interact with carcinogens.
Viruses such as the human immunodeficiency
virus (HIV) can damage the immune system and
decrease immunocompetence, causing the body
to become more susceptible to the growth of
abnormal cells.
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Viruses (Cont.)
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The hepatitis B virus is carcinogenic for liver
cancer.
The Epstein-Barr virus causes Burkitt’s
lymphoma.
Cases of adult T-cell leukemia and lymphoma
are caused by human T-cell lymphotropic
virus.
Several types of the HPV cause cervical
carcinoma and are related to throat and
mouth cancer in nonsmokers.
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Genetic Predisposition
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Research is revealing that there is a genetic
predisposition to various types of cancer.
Breast cancer is more likely to occur in
women who have a close female relative who
developed breast cancer before the age of 50
years.
Gene markers have been found for colon
cancer, breast cancer, prostate cancer,
pancreatic cancer, and leukemia.
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Genetic Predisposition (Cont.)
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However, only 5% to 10% of cancers are
related to a directly inherited gene.
The remaining cancers are caused by genes
that are damaged (mutated) throughout the
lifetime and are not inherited.
Some people are more susceptible to these
mutations.
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Cultural Considerations
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Some populations are at a higher risk for
certain types of cancer.
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Of the four types of melanoma, African Americans
are most susceptible to the acral lentiginous type,
and whites are least susceptible to it.
Lentigo maligna melanoma is found most often in
Hawaii.
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Human Genome Project
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Current research is focused on finding
genetic markers, or oncogenes.
Such markers, or the proteins they produce,
could identify high-risk individuals who then
might undergo more vigorous, regular
diagnostic testing to detect any malignancy in
the very earliest stages.
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Contributing Factors
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Intrinsic factors
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Age
Sex
Race
Stress
Diet
Alcohol
Exposure to carcinogens
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Diet and Nutrition
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Encourage maintenance of normal weight.
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Obesity is considered a risk factor in many
cancers.
It also makes early detection of many cancers
difficult.
Nitrite and nitrate food additives are also
known to be cancer stimulators (encouraging
cancer).
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Alcohol
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Moderation in the drinking of alcohol is
recommended because alcohol consumption
alone has been shown to increase risk for
several cancers.
Excessive alcohol consumption also can lead
to liver damage and possibly to liver cancer.
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46
Warning Signs of Cancer
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Unusual bleeding or discharge
A sore that does not heal
A change in bowel or bladder habits
A lump in the breast or other part of the body
A nagging cough
An obvious change in a mole
Difficulty swallowing
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Older Adult Care Points
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Older patients are at increasingly higher risk
for developing cancer.
Their immune systems are not as efficient as
that of a younger person.
Many of the cancer screening programs are
suggested to begin at age 40 or 50 years.
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Diagnostic Tests
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Biopsy
Radiologic studies
Endoscopy
Laboratory tests
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Biopsy
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Biopsy is the removal of living cells for the
purpose of examining them under a
microscope
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Surgical excision—cutting out
Aspiration—suction
Frozen section
Fine-needle aspiration
Percutaneous
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Radiologic Studies
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Mammography
Radionuclide or isotope—tumor seeking
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Cold spot—tumor does not accept the isotope
Hot spot—tumor accepts the isotope
Computed tomography (CT) scanning
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Noninvasive
Reveals the size, shape, contour, and density of
an organ
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Radiologic Studies (Cont.)
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Magnetic resonance imaging (MRI)
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View “slices” of tissue
Can sometimes “see” tumors and abnormalities
that other techniques miss
Patients with pacemakers, certain metal fragments
or clips, or shrapnel in the body cannot use MRI
because the powerful magnets used in this
technique can bend and twist metal and can
damage the body.
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Laboratory Tests
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CBC
Prostate-specific antigen (PSA)
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Current recommendations include offering a
baseline PSA test for male patients older than 50
years.
To be repeated at various intervals depending on
the patient’s risk factors
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Laboratory Tests (Cont.)
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Tumor markers
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CA-125 is used to detect the presence of ovarian
cancer or its recurrence after therapy.
Carcinoembryonic antigen (CEA) and CA 19-9
detect the recurrence of gastrointestinal,
pancreatic, and liver cancer after initial treatment.
CA 27-29 is used most frequently to follow the
progress in breast cancer treatment and later to
check for recurrence.
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Assessment
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Comprehensive assessments include
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Physiological effects of the disease
Patient knowledge and understanding of disease
process, treatment, and prognosis
Psychosocial needs of patient and family
Anticipation of therapeutic effects of various
treatment modalities
Preparation for lifestyle changes and anticipation
of death
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Planning
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Patient will remain free from infection.
Patient will remain free from hemorrhage.
Patient will verbalize relief from nausea.
Patient will be able to eat with minimal
discomfort.
Patient will maintain present weight.
Patient will adjust to new body image within 3
weeks as evidenced by verbalization.
Patient will verbalize fears and develop coping
mechanisms to decrease fear.
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Evaluation
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Determine whether the expected outcomes
specified for the patient are being met or
have been met.
Assess signs of complications, side effects of
therapy, nutritional status, and pain.
Change ineffective interventions to meet
desired outcomes.
Collaborate with the patient and the other
members of the health care team.
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Common Therapies, Problems,
and Nursing Care
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Surgery, radiation, and chemotherapy
Hormone manipulation, immunotherapy with
biologic response modifiers, and bone
marrow or stem cell transplantation
Each of the modes of treatment may be used
singly or in combination with one or more of
the other methods available.
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Surgery
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Biopsy—obtain specimen
Prophylaxis—preventive treatment
Explorative—determine effectiveness of
therapy
Palliative—offer pain relief
Curative—attempt cure
Reconstructive
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Radiation Therapy
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Radiation destroys malignant cells (which are
more sensitive to radiation than are normal
cells) without permanent damage to adjacent
body tissues.
The course of radiation is spread over a
period of days to weeks.
The RAD (radiation absorbed dose) is the
unit used for measuring dosages of radiation.
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Considerations for Using Radiation
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Tumor sensitivity to radiation
Tumor location
Tumor size
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Internal Radiation Therapy
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Involves introducing a radioactive element
into the body
The material may be administered in different
ways.
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Placed in a sealed container and inserted into a
body cavity at the site of the tumor or placed
directly into the tumor
Administered in an unsealed form and taken orally
or injected by syringe
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Internal Radiation Therapy (Cont.)
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The radiation source must come into direct
contact with the tumor tissue for a specified
time.
Most implants emit a lower level of radiation
while in constant contact with the tumor cells.
Because the radiation source is within the
patient, radiation is emitted for a period and
can be a hazard to others.
Nurses caring for patients receiving internal
radiation must take extra precautions.
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Radiation Exposure
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The amount of radiation a nurse might
receive while caring for a patient being
treated with internal radioactive elements
depends on three factors:
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The distance between the nurse and the patient
The amount of time spent in actual proximity to the
patient
The degree of shielding provided
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Radioactivity
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As soon as an element becomes radioactive, it
begins to lose its characteristic of radioactivity.
The rate at which it becomes less radioactive is
called its half-life, which is the amount of time it takes
for half of its radioactivity to dissipate.
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Whereas the half-life of radium is about 1600 years,
the half-life of iodine is only about 8 days.
Cesium is a radioactive element frequently used to
treat malignancies of the mouth, tongue, vagina, and
uterine cervix.
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Isotopes
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Some isotopes are given orally, and others
are administered into a body cavity.
The isotopes are unsealed sources of
radiation.
If radioactivity is a hazard, it is a problem only
for the duration of the half-life of the isotope.
The substance is eliminated through body
secretions such as sweat, sputum, vomit,
urine, or feces.
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Ionizing Radiation
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Ionizing radiation can have both an
immediate and a delayed effect on malignant
cells.
It can damage the cell membrane
immediately, causing lysis (bursting) or
decomposition of the cell, or it can cause a
break in both strands of the DNA in the cell’s
nucleus.
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External Radiation Therapy
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Nursing care goals
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Help the patient and family cope with the
diagnosis of cancer and its treatment with
radiation therapy.
Teach the patient and family how to recognize and
manage the expected side effects of radiation.
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Audience Response Question 1
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In helping a 40-year-old patient cope with breast
cancer, the nurse should help the patient focus
on which aspect(s) of radiation therapy and care?
(Select all that apply.)
1.
2.
3.
4.
5.
Complying with scheduled radiation therapies
Taking precautions on exposing other family
members
Protecting the skin by applying lotion
Wearing snug-fitting clothing
Understanding the therapeutic effects and side
effects
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Chemotherapy
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Antineoplastic agents
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Decrease the number of malignant cells in a
generalized malignancy (e.g., leukemia) or to reduce
the size of a localized tumor and thereby lessen the
severity of symptoms
Cytotoxic agents
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Poisonous to cells; however, normal cells do not
reproduce in exactly the same way as malignant cells,
so normal cells are able to repair themselves more
rapidly and effectively
Steroids often are used in combination with
antineoplastic drugs for cancer treatment.
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Chemotherapy (Cont.)
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Techniques of administration
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Intra-arterial
Intraperitoneal
Intraventricular
Intrathecal (within a space of the spine)
Intravenous infusion
Vesicants
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Chemicals causing tissue damage upon direct
contact
Can cause severe local injury if they escape from
the vein into which they are administered
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Nursing Implications for Chemotherapy
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Toxicity on cells that have a short lifespan
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Blood cells
Hair follicles
Epithelial cells of mucous membranes
Most chemotherapeutic agents are excreted
in body fluids.
Most are teratogenic (can cause birth
defects).
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Hormone Therapy
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Used as an adjunct to other types of cancer
therapy
Can slow tumor growth or prevent cancer
recurrence
When a hormone is added to the body, the
balance of naturally produced hormones
changes.
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Hormone Therapy (Cont.)
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Giving large amounts of one hormone
prevents the uptake of other hormones.
If the tumor growth is aided by one type of
hormone, giving another type prevents the
uptake of the growth-promoting hormone and
slows the progress of the tumor.
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Side Effects of Hormone Therapy
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Androgens and antiestrogen receptor drugs
produce masculinizing effects in women.
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Facial and chest hair
Menses may stop
Breast tissue will shrink
Fluid retention
Acne
Hypercalcemia and liver dysfunction can occur
with prolonged therapy.
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Side Effects of Hormone Therapy
(Cont.)
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In men taking estrogens or progestins to combat
prostate cancer, there is a feminizing effect.
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Decreased facial hair
Redistribution of body fat
Breast development (gynecomastia)
Smoothing of the facial skin
Risk of thrombus formation
Over time, testicular and penile atrophy may occur,
and it may become more difficult to attain and
maintain an erection.
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Immunotherapy Using Biologic
Response Modifiers
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Biologic response modifiers
Interferons and interleukins
Monoclonal antibodies (MoAbs)
Cancer vaccines
Immunomodulating agents
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Biologic Response Modifiers (BRMs)

Agents that manipulate the immune system in
the hope of controlling or curing a malignancy
with little or no toxic effect on normal cells



Either stimulate or suppress immune activity
BRMs stimulate the immune system to recognize
cancer cells and to institute action to destroy them
Enhance a quicker recovery of the bone marrow
after radiation or chemotherapy
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78
Interleukins and Interferons


Interleukins help the immune system cells
recognize and destroy abnormal cells.
Interferons slow down cell division in cancer
cells, stimulate natural killer cells, hold back
the appearance of oncogenes, and assist
cancerous cells to revert back to more normal
cells.
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79
Monoclonal Antibodies (MoAbs)


Direct antitumor effects
Rituximab (Rituxan) and trastuzumab
(Herceptin) are examples of MoAbs that have
been approved by the U.S. Food and Drug
Administration.
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80
Cancer Vaccines


Stimulate the immune system to attack the
cancer cells (therapeutic)
Stimulate the production of antibodies against
a cancer-causing virus (prophylactic)
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81
Nonspecific Immunomodulating Agents

May stimulate the immune system and either
restore depressed immune function or
increase immune inflammatory responses
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82
Other Therapies



Bone marrow transplant
Stem cells
Gene therapy
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83
Evaluating Effectiveness of Medical
Treatment

Second-look surgery


The oncologist conducts an ongoing evaluation of
each patient’s status to determine how effective
the prescribed treatment has been and to plan for
a future course of therapy if it is needed.
It is particularly important to know whether there
has been a reduction in the size of the tumor and
an abatement of the patient’s symptoms—this is
the purpose of “second-look surgery.”
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84
Tumor Marker Levels

CEA



Glycoprotein produced during fetal life but not
normally present after birth
Its production may resume again, however, and
CEA levels can be increased by some kinds of
liver disease, heavy cigarette smoking, and
especially by gastrointestinal and colorectal
cancers.
Can be used as a tumor marker to evaluate the
effectiveness of treatment because CEA levels
usually fall to within the normal range about 1
month after successful treatment of cancer
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85
Tumor Marker Levels (Cont.)

PSA


Prostate cancer
CA-125

Ovarian cancer
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86
Complementary and Integrative
Medicines

Therapies used in addition to—but not as a
replacement for—traditional Western
(allopathic) medicine
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87
Common Problems Related to Cancer or
Cancer Treatment






Anorexia and
malnutrition
Mucositis and oral care
Significant weight loss
of 2 or more lb per
week
Nausea, vomiting, and
diarrhea
Constipation
Cystitis







Immunosuppression
and decreased white
blood cells (WBCs)
Anemia
Bleeding problems
Hyperuricemia
Fatigue
Alopecia
Pain
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88
Anorexia



Loss of appetite
Often associated with changes in taste and
with inflammation of the mouth and tongue
Megestrol (Megace) (female hormone) has
proven to work well to stimulate the appetite.
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89
Anorexia (Cont.)

Nursing implications




Thorough mouth care should be started several
days before the beginning of chemotherapy or
radiation therapy to the head and neck.
Frequent oral intake of liquids that are not irritating
chemically
Use of artificial saliva helps to buffer the acidity in
the mouth and thus to reduce irritation of the oral
mucosa.
Frequent and consistent mouth care to preserve
teeth and prevent infections of the gums
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90
Mucositis

Irritation and inflammation of the mucosa in
the mouth
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91
Mucositis (Cont.)

Patient teaching






Encourage consistent oral hygiene.
Use a soft brush or tooth sponges.
Irrigate the mouth to remove debris and
counteract acidity.
Increase fluid intake to 3000 mL/day.
Relieve mouth pain of mucositis or stomatitis
(inflammation of the mouth) with special topical
compounds (e.g., Xylocaine Viscous).
Avoid spicy foods, alcohol, and tobacco.
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92
Weight Loss

Nursing implications






Monitor weight.
Increase protein intake.
Small, frequent feedings.
Attend to preferences for foods.
Provide pleasant and restful environment during
meals.
Supplement feedings.
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93
Nausea and Vomiting

Caused by radiation therapy of the abdomen
or lower back often starting 7 to 10 days after
the beginning of treatment
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94
Nausea and Vomiting (Cont.)

Nursing implications





Choose antiemetic regimens based on potential of
chemotherapy regimen to cause nausea.
Encouraging eating before treatment seems to
decrease nausea.
Give liquids, liquid supplements, or easily digested
foods at 3- to 4-hour intervals in small amounts.
Provide comfort measures and mouth care.
Monitor for dehydration and electrolyte imbalances
when excessive vomiting occurs.
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95
Diarrhea

Caused by radiation to the abdomen, lower
back, or pelvis, chemotherapy effect on
intestinal mucosa
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Diarrhea (Cont.)

Patient teaching




Avoid high-fiber foods.
Add low-fiber foods such as bananas and cheese.
Cleanse rectal area and apply petroleum jelly,
A&D ointment, or Desitin cream to decrease
discomfort and prevent skin breakdown.
Monitor for signs of dehydration and electrolyte
imbalance.
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97
Constipation

Certain antineoplastic drugs, such as
vincristine, vinblastine, and taxol, cause
constipation.
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Constipation (Cont.)

Patient teaching






Increase fluids (as allowed).
Add fiber to the diet.
Administer stool softeners and fiber laxatives.
Exercise.
Monitor for the beginning signs of constipation.
Consider suppositories or enemas.
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Cystitis

Caused by Cytoxan and ifosfamide
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Cystitis (Cont.)

Patient teaching




Monitor for hesitancy, urgency, and pain during
urination.
Check urine for cloudiness and signs of hematuria
(blood in the urine).
Increase fluids to 2 to 3 L/day.
Encourage frequent bladder emptying.
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Bone Marrow Suppression





Major reason that doses of chemotherapy
must be limited
Slows production of erythrocytes, leukocytes,
platelets
Some can cause severe suppression
Usually is temporary
Improvement in bone marrow function occurs
within weeks to months of completed therapy.
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102
Bone Marrow Suppression (Cont.)



WBC count monitored for a count of less than
3000/mm3, indicating neutropenia
Neupogen or Leukine is given to raise the
neutrophil count and the WBC count.
Often administration of these agents is
started before the WBC count drops low.
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103
Bone Marrow Suppression (Cont.)

Nursing implications




Anemia places an increased workload on the
heart and lungs.
When the platelet count reaches a low of
50,000/mm3, any small injury can lead to an
episode of prolonged bleeding.
At 20,000/mm3, spontaneous bleeding that is
difficult to control may occur.
If less than 50,000/mm3, bleeding precautions are
observed.
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104
Bone Marrow Suppression (Cont.)






If less than 10,000 to 15,000/mm3, the patient is
transfused.
Administer platelets if the count falls to
20,000/mm3.
Take measures to help lower the risk of bleeding.
Be gentle.
Avoid irritating foods.
Prevent infection.
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105
Infection Prevention

Report the following signs of infection to the
physician immediately.





Temperature over 100º F (38º C)
Persistent cough
Colored or foul-smelling drainage from wound or
nose
Presence of a boil or abscess
Cloudy, foul-smelling urine or burning on urination
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106
Hyperuricemia

Caused by antimetabolite destruction of
cancer cells
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107
Hyperuricemia (Cont.)

Nursing implications


Encourage high fluid intake to prevent problems of
hyperuricemia (high uric acid in the blood).
Administer allopurinol to decrease the incidence of
gout caused by the hyperuricemia; it is started at
the beginning of therapy in an effort to prevent the
problem.
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Fatigue




Fatigue from immunosuppression treatment
requires an adjustment of lifestyle.
The patient may feel tired and without energy.
The patient may be impatient and irritable
and withdraw from social environment.
A decrease in activity may lead to a decline in
function that is irreversible.
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109
Fatigue (Cont.)

Patient teaching








Avoid unnecessary bed rest.
Maintain a good balance between energy and activity.
Minimize emotional distress.
Maintaining activities of daily living.
Use energy-saving devices and prioritizing activities.
Maintain a good nutritional status with high protein
intake.
Supplement meals to ensure adequate calorie intake.
Increase fluids to 3 L/day on day 3 unless
contraindicated.
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110
Alopecia


Hair loss (alopecia) resulting from chemotherapy is
temporary.
Occasionally, radiation therapy to the head causes
permanent hair loss.
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111
Alopecia (Cont.)

Patient teaching



Hair begins regrowth about 1 month after
chemotherapy ends.
New hair may be different in texture and color
from the original hair.
Before hair loss occurs, the patient should decide
if he or she will wear a wig or head cover until the
hair is regrown.
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112
Pain




For many cancer patients, pain is a daily
reality.
Pain reduces appetite, limits activity, and
interferes with sleep.
Most cancer pain (90%) can be relieved or at
least controlled by a combination of
measures.
Often, however, the pain of cancer is
undertreated.
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113
Pain (Cont.)

Pain must be




Assessed and documented regularly
Discussed openly with family and the reports of
pain must be believed and understood
Addressed with options that are appropriate for
the setting and for family
Treated with interventions in a timely fashion
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114
Nonpharmacologic Interventions

Nonpharmacologic interventions are
combined with oral, topical, and parenteral
analgesia to achieve relief or good control of
pain.
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115
Fear and Ineffective Coping





Assess the patient’s and family’s usual coping
techniques.
Pay attention to the patient’s partner.
Be honest about the adverse effects but take
a positive approach.
Consider psychosocial and spiritual care.
Assist the patient to use strengths in planning
for fighting the disease.
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116
Fear and Ineffective Coping (Cont.)




Coordinate family strengths to continue with
daily life.
Speak with the patient and partner about
sexual concerns.
Refer to a social worker to coordinate
resources.
Encourage a sense of humor and looking for
little pleasure and enjoyment in life on a daily
basis.
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117
Oncologic Emergencies






Tumor lysis syndrome, including
hyperkalemia and hypercalcemia
Hypercalcemia
Disseminated intravascular coagulation (DIC)
Pericardial effusion and cardiac tamponade
Spinal cord compression
Superior vena cava syndrome
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118
Common Fears of the Dying Patient






The unknown
Abandonment and loneliness
Loss of relationships
Loss of experiences in the future
Dependency and loss of independence
Pain
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119
Common Fears of the Dying Patient
(Cont.)

Nursing Implications





The nurse is most helpful to the patient in just
“being there” for the patient and expressing caring.
Provide comfort and strength for the patient.
Explain to the family that patients go through
these stages and the behavior is normal.
Review own beliefs about death and dying and
reaffirm those beliefs.
Take a periodic inventory of your ability to provide
care without “burnout.”
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120
Kübler-Ross’ Stages of Dying





Denial (This can’t happen to me!)
Anger (Why me?)
Bargaining (Yes me, but. . .)
Depression (It is me. I give up. . .)
Acceptance (I’m ready. . .)
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121
Palliative Care

Palliative care (comfort care) is directed at
meeting the needs of the dying patient by
providing comfort and maintaining a high
quality of life.
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122
Palliative Care (Cont.)



Anticipatory guidance and stages of dying
Terminal hydration
End-stage symptom management




Pain
Dyspnea
Death rattle
Delirium
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123
Anticipatory Guidance


Prepare the family and patient by anticipating
the death.
Give guidance about physical changes,
symptoms, and complications.


This may also aid the patient and family in
deciding about possible hospice care.
Two stages of dying


Pre-active, which may take weeks or months
Active, which lasts only a few days
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124
Terminal Hydration



A dying patient gradually reduces fluid intake.
Dehydration can increase because of the
disease process.
Dry mouth and thirst may be induced by
drugs.
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125
Terminal Hydration (Cont.)

Nursing implications


The nurse must educate the patient and family on
the benefits and burdens of hydration.
Many times, the course is for patients to choose
what to take and to be allowed to refuse further
nourishment.
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126
End-Stage Symptom Management

Comfort is the goal of palliative care.



Administering only oral medications is the
preferred choice, but this may not be possible as
death draws near.
The goal is to allow a pain-free death.
In some cases, it may be possible to administer
transdermal or rectal pain medications.
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127
Pain



Transdermal fentanyl has helped eliminate
the burden of pain at the end of life.
Sometimes this regimen is supplemented
with rescue doses of morphine.
Whatever the regimen, studies have shown
that pain relief, either total or at least enough
to make the pain tolerable, is possible 75% to
97% of the time.
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128
Dyspnea


When patients are near death, they often
subjectively feel as if they cannot get enough
air.
It is difficult to determine what causes this
feeling, but several measures can be taken.




Place in Fowler’s position.
Reduce activities.
Adjust air temperature.
Give bronchodilators and morphine to ease
breathing.
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129
Death Rattle



Noisy ventilation is heard when patients can
no longer clear their throats of normal
secretions.
Family members are often alarmed and are
afraid the patient will choke to death.
In these cases, scopolamine or atropine,
drugs that are known to reduce secretions,
may be used to quiet the patient and bring
breathing back to normal.
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130
Delirium



Dying patients may experience hallucinations
or altered mental status.
The nurse must first search for causes such
as pain, positional discomfort, or bladder
distention and address those physical
problems.
The nurse should discuss the delirium with
the patient’s family and encourage the family
to talk to the patient in quiet tones while
remaining calm.
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131
Audience Response Question 2

A terminally ill woman reminiscing about the
“good old days” becomes increasingly
confused and talks of seeing relatives who
have died. Which nursing intervention(s)
would be appropriate? (Select all that apply.)
1.
2.
3.
4.
5.
Discuss the patient’s behaviors with the family.
Force oral fluids.
Encourage the family to talk to the patient in quiet
tones.
Promote a calm environment.
Apply physical restraints.
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132