Transcript cancer - Faculty Sites

CANCER/TRANSPLANT/End OF LIFE
BY: Diana Blum MSN
Metropolitan Community College
NURS 2150

This ppt created with the help of material from
Osborne, K. et al (2010) Medical Surgical Nursing
Preparation for Practice. Pearson: Boston.
GOAL OF CANCER CARE
Combination
of
treatments
effective in
controlling most
cancers

http://www.youtube.com/watch?v=j_wRpa2b5XI
CARCINOGEN

Any chemical, physical, or genetic agent that can
irreversibly alter cellular DNA

Abnormal cells produced

Tobacco smoke – can both initiate & promote
cancer growth
ROLE OF IMMUNE SYSTEM
Surveillance
of
tumor-associated
antigens
2nd leading cause of death in USA
Metastasizing cancer
Cell
1 out of 4 Americans
will have CA at some
time in their life
Definition

According to the American Cancer
Society:

A large group of diseases
characterized by uncontrolled
growth and spread of abnormal
cells
Top 3 Cancers that cause Deaths
figure 64-1
 Men
 Women

Lung

Lung

Prostate

Breast

Colorectal

Colorectal
Neoplasm (aka TUMOR)

Cells that reproduce abnormally and in an uncontrolled manner
4 types of Malignancies
 Carcinoma: skin, glands, lining of
digestive urinary and reproductive
tracts
 Sarcoma: bone, muscle, other
connective tissues
 Melanomas: pigment cells in the
skin
 Leukemias and lymphomas: blood
forming tissues: lymphoid tissue,
plasma cells, and bone marrow
Early Diagnosis Is
Key for survival
7 Warning Signs

C – change in bowel or bladder habits

A – a sore that does not heal

U – unusual bleeding or discharge

T - thickening or lump in breast or other

I – indigestion or difficulty swallowing

O – obvious change in wart or mole

N - nagging cough or hoarseness
Staging
Stage 1

The malignant cells are confined to the tissue of
origin. Not invasive with other tissues
Stage 2

Limited spread of the cancer in the local area
usually near lymph nodes
Stage 3

The tumor is larger or has spread from the local site
of origin into nearby tissues

regional lymph nodes are likely to be involved
Stage 4

The cancer has metastasized to distant parts of the
body
THE TNM Staging System

Specifies the status of the primary tumor, regional lymph nodes,
and distant mets

T: tumor

N: regional nodes

M: distant mets
Malignant Transformation

4 steps

Initiation: DNA exposed to carcinogen

Promotion: sufficient exposure to agent to
encourage/enhance cell growth

Progression: accelerated growth, enhanced invasion,
altered appearance and activity

Metastasis: tumor develops blood vessels

Penetrates capillaries and form fibrin network (undetectable by
immune system)

Dissolve lining of blood vessels to invade surrounding tissue

Set up their own blood supply
Treatments

Surgery:

Done for:

diagnosis
 Symptom relief
 maintain function
 Reconstruction
 Possible cure
Surgery continued

Preop/postop care varies

The recommended treatment is based on the
cancers: type, location, and mets
Radiotherapy

Uses ionizing radiation

Dose: 1 gray equals 100 rads

Used to treat malignant cells

Has delayed and immediate effects

Delayed: altered DNA which impairs the cells ability to
reproduce

Immediate: cell death due to damage of cell
membrane
Figure 64.4 Immobilizers for
radiation therapy.
From Osborne Book
Caregiver Safety with radiation

The less time spent near the source the less
exposure

Unless direct care being given stay 6 ft away from
the source

Effective shielding depends on type of rays (the
denser the material the more protection)
External radiation

PROCEDURE

Source is outside the body

Special xray machine provides treatment

# of treatments depends on the doctor


Example: 5 times a week for 2-8 weeks
PATIENT PREP

Treatment simulation to determine exact dosage
needed and schedule

The skin is marked with permanent, waterproof ink,
by the radiologist for the exact site

Instruct client not to remove markings without
permission
Internal Radiation (Brachytherapy)

PROCEDURE

Sources

Iodine, phosphorus, radium, iridium, radon, cesium

Instruct client that they pose a threat until the
source is removed unless permanently implanted
small beads used

2 TYPES

Sealed

Unsealed
Sealed
Source is sealed in a container and inserted into the
body (CESIUM)
 Sources may be placed in threads, beads, needles,
seeds, or molds
 To protect visitors from exposure the client needs:


To be placed in isolation

Have a sign on the door indicating radiation

No pregnant women or kids under 18 allowed in room

Limit time with visitors

Have organized schedule for cares
Figure 64.5 Brachytherapy
applicator.
From Osborne Book

Staff to wear film badges to monitor exposure

Recognize that Sealed sources can become dislodged


Portable lead shields provides minimal protection
Immediately notify MD if source becomes
dislodged.
Do not touch source with bare hands
Unsealed

Body fluids may be contaminated

Must wear gloves when working with patient

Contaminated fluids, dressings, etc may require additional precautions
depending on the agency.

Disposable utensils are recommended

Equipment being removed from room must be checked for radiation level
first
Radiation side effects

Normal cells may be harmed (hair follicles, bone
marrow, lining of gi tractand urinary tract)

Anemia-deficiency of RBC

Low WBCs


Take 2-6 wks to recover
Bruising/Bleeding( low platelets)

Takes 2-6 wks to recover

Alopecia (hair loss)

Anorexia

Dry mouth

Harms reproductive cells
Chemotherapy

Use of chemical agents to treat (Antineoplastics)

Destroy rapidly dividing cells

Curative in some cases

Decreases symptoms in others
Chemotherapy and the Cell
Cycle

Stages of cancer:



Initiation (alteration of
cell’s genetic structure)
Promotion (reversible
proliferation of altered
initiated cells)
Progression (increase in
growth rate and possible
metastasis)

Chemo kills at a constant % of
cancer cells

Can be cell cycle specific
(G(1), S, G(2), or M) or

Cell Cycle non-specific - G(0)
or dividing phase
Chemotherapy Categories
 Alkylating
agents
 Nitrosourea
ses
 Plant
Alkaloids
 Antitumor
Antibiotics

Antimetabolit
es

Hormonal
agents

Miscellaneous
agents such as
:

L-asparaginase

Procarbazine
Chemotherapy
Use
of chemical agents to
treat cancer (Antineoplastics)
Destroy rapidly dividing cells

Can
be done with or without
radiation
Complication:

Extravasation – STOP DRUG
IMMEDIATELY!!
Chemotherapy

Other Complications:


Nadir


Lowest point in cell count after
chemo/radiation – highest risk for
infection
Neutropenia


Bone marrow suppression
7-14 days after chemo
Absolute Neutrophil Count (ANC)

Limitations of chemotherapy:

Few agents cross the blood-brain barrier

The phenomenon of resistant tumor

Most agents are most effective on dividing cells, but…

As a tumor grows, more cells become inactive
From Osborne Book
From Osborne Book
Chart 64-21 (continued) Routes of
Administration
From Osborne Book
From Osborne Book
Chart 64-21 (continued) Routes of
Administration
From Osborne Book
From Osborne Book
Cancer Drug Examples

5FU

Megace
Side effects and toxicities
The result of the destruction of normal cells
Fast-growing cells most susceptible to damage
Cell destruction → fatigue, anorexia, and taste alterations
Gastrointestinal system effects
Genitourinary system effects
Nursing management related to side effects and
toxicities
From Osborne Book
Side Effect Management

Drink 8-12 cups of clear liquid a day

Small frequent meals

Bland foods

Rest

Encourage wig

Be gentle with hair washing

No styling products

Check mouth for sores

No sugar

Drinks room temp

Do not rub/scratch skin
MANAGEMENT

Continue
dexamethasone

Begin radiation to
affected area

Opioid medications to
manage pain

Analgesics ATC &
additional doses for
breakthrough pain

Laxative to prevent &
manage constipation

Physical therapy
NUTRITION

The nutritional status of cancer patients can be altered in a variety of ways

Anorexia, or loss of appetite, usually peaks 4 weeks into treatment and
subsides shortly after treatment ends

Cancer cachexia

Nutritional screening

Nutritional support: oral nutrition, enteral feedings, parenteral nutritional
support

Artificial nutrition and hydration can raise ethical questions for patients who have
cancer, particularly those at end of life
From Osborne Book
Figure 64.7 Cancer cachexia. Source:
© Welcome Trust Images/Custom
Medical Stock Photo
From Osborne Book
Biotherapy

Treatment with agents whose origin is from
biological sources and/or affects biological
responses

monoclonal antibodies and cytokines

hematopoietic growth factors

interferons (INF)

interleukins
From Osborne Book
Uses of Biologic Response
Modifiers

Definition- natural
substances produced
in small amts. by
body’s immune system;
reproduced by
recombinant DNA
technology

How does this differ
from chemotherapy?

Goal – enhance pts.
Immunologic response
to tumor cells
Three categories based on
Activity of BRM

Modulation or induce a
host’s recognition to a
tumor:




Intron A (alpha interferon)
anti viral
Interleukin-2 : T/B
lymphocytes
cause flu-like S&S
premedicate, labs, VS,
check I & O & monitor for
arrhythmias

Tumoricidal action


TNF, monoclonal antibodies,
LAK, TIL (activated by
interleukin-2)
Colony stimulating factors:

G-CSF (Neupogen), GM-CSF
(Leukine), EPO (Procrit)
Transplants and hormone therapy

Bone marrow- used with leukemia/lymphoma

Stem cell- bone marrow depression

Umbilical cord blood


These 3 are done to restore blood manufacturing
cells
Hormone therapy-used to supress natural
hormone secretion, block hormone actions, or
provide supplemental hormones
From Osborne Book
Complications of transplantation
Primarily due to the conditioning regime
Can include bleeding, infection, nausea and
vomiting, diarrhea, mucositis, and graftversus-host disease (GVHD)
May also have late effects
Nurses must be aware of the signs of
graft failure and GVHD
Graft failure rare, but nurse must
expertly assess patient
Requires another transplant or death
will result
From Osborne Book
Oncological emergencies

Hypercalcemia

Syndrome of inappropriate antidiuretic
hormone (fluid does not come off)

Disseminated intravascular coagulation (DIC)

Superior Vena Cava Syndrome (redness/edema
of face, tachycardia, distended neck veins)


Teach client not to bend forward
Spinal cord compression secondary to tumor
From Osborne Book
Nurse’s Role in early detection/
prevention for Septic Shock

Check vital signs, shaking,
chills, hypotension

Report temperature of 100.4
or above

Check skin for rash

Check peripheral or central IV
sites

Avoid injections

Assess pulmonary
function

Check urine changes

Avoid catheterization

Control environment

Give CSF & antibiotics
Three phases of Septic Shock


Phase I -warm stage, caused by gram
negative organisms

increase heart rate, skin warm, increased temp.

antibiotics need to be started immediately
Phase II - warm to cold stage


shift of fluid, cold, clammy, decreased bp,
increased pulse, decreased urine output
give IV fluids, lasix, dopamine
Phase III of Septic Shock

Full cold stage

Alteration of cardiac
output

Monitor hemodynamics

Give dopamine,
dobutamine, IV fluid
to maintain PAWP bet.
12-18, ventilate
Chart 64-24 (continued)
Oncologic Emergencies
From Osborne Book
From Osborne Book
Other possible Oncologic
Emergencies
 What
cause
them?



would

Tumor Lysis
Syndrome

DIC
Pericardial
effusion/ca
rdiac
tamponade
SIADH

tumor destroys
cells and
releases cellular
components that
form imbalances
: increased K, P,
uric acid;
decreased
calcium
Rx: allopurinal,
Ca, dialysis
Quality of Life

The oncology nurse can positively affect QOL by
prioritizing symptoms and implementing
appropriate relief measures

For patients at end of life, nurses should be familiar
with the concepts of hospice and palliative care
From Osborne Book
Survivorship

What does the 5
year survival rate
mean?

Extended survival
has certain
considerations:


teaching needs

resocialization

employment

insurance coverage
American Cancer
End of Life and
Transplantation
By Diana Blum RN MSN
Metropolitan Community College
Nurs 2150
End of Life

Death: lungs and heart cease to function

Causes: illness or trauma that overwhelms the body

Direct causes are: respiratory failure or shock
Multi-organ failure

Inadequate blood flow to body tissues deprive cells of oxygen which
leads to acidosis, hyperkalemia, and tissue ischemia

First organs hit: kidneys, liver, heart, brain
›
May also be in lung with septicemia

Vfib, asystole, or PEA can occur at any point of shock or hypoxemia

After cardiac arrest, respiratory arrest occurs within minutes

Clinical death refers to cessation of heartbeat and breathing with no
evidence of brain function present
Incidence of death

Dying is a part of life cycle

2.5 or more people die each year in the USA from CAD and cancer
Natural process

Stages of death
›
Pallor mortis: body becomes pale. 15-120 minutes post death
›
Algor mortis: body temp falls
›
Rigor mortis: muscle stiffness. Relaxation occurs after about 72 hours post
onset of rigor
›
Liver mortis: blood begins to pool on lowest part example: to back if lying on
back. 20 minutes to 3 hours after death
›
Decomposition: we start to decompose

http://www.youtube.com/watch?v=BuF5qxIDa3c

http://www.youtube.com/watch?v=Qo5mCB9gbfY&feature=PlayList&p=
C477E57325CB86CC&index=0
care

Palliative: philosophy that provides compassion and supportive approach
to the dying

Helps to relieve symptoms

Provides emotional and spiritual support
Hospice as a Consideration

Symptom control and pain management

Comfort and dignity is a philosophy

First hospice in USA in 1974 in New Haven,
Conn.

Eligibility: life expectancy of 6 months or
less

24 hour, 7 day /week coverage
HOSPICE
Hospice
is not a
building – it is a
model of care
Distress symptoms

Pain

Dyspnea

n/v

Fatigue

Weakness

Constipation

Anorexia

delirium
Assessments

Past medical hx

Assess emotions (see next slide)

Assess LOC

Teach family signs of distress (pain, restlessness, moaning)

Assess skin for temp, color, mottling, cyanosis

Assess vs: they will drop as death nears

Assess culture for customs/rituals

Assess lungs for cheyne stokes

Provide a comfortable environment (music, massage, no restraints, family
near, lights dim, etc)
Emotions with impending death

Withdrawl is 1st

Vision like appearances

›
Talk/mumble to people that are not present
›
Picking at air
›
Affirm their experience
Letting go
›

May be agitated or perform repetitive tasks
Saying goodbye
›
Saying goodbye is important
›
Touching, hugging, saying I love you, crying is okay
›
Acknowledge these expressions as natural end
Tx

Pain management

Fatigue management

Dyspnea management

Oxygen

n/v management

Agitation management

Grief management for pt and family

Offer support

Be realistic

Encourage reminiscence

Promote spirituality

Foster hope
Post mortem care

Pronouncement of death

Call PCP and other care providers

Call NORS

Allow family to view body

At Alegent, security or pastoral care will go over funeral arraignments
like mortuary

At Alegent, a silk rose is placed on the door and given to family when
they leave as well as the belongings of the deceased
Euthanasia

Passive: involves withdrawing or withholding tx that might prolong the
life of a person who cannot be cured


This is accepted by all
Active : involves a healthcare provider taking action that purposefully and
directly causes the client’s death

This is not allowed
Advance Directives

Written document that specifies the client’s wishes should something
happen to them.

DPOA-HC: appoints someone to make decisions in the event the client is
unable

Living will: instructs doctors and family what life sustaining or lack of
they wish to have done.
Why
Transplant?
Transplantations

http://www.youtube.com/watch?v=SvxpyfZ9Rsk
The Road to Transplant

Treatment

Evaluation by a
major transplant
center

Listed or Not
Listed

Waiting
Evaluation for Transplant

3-4 day process

Many tests: extensive lab
work (40+ labs), ultrasounds,
doppler studies, x-rays, bone
scan, echocardiogram, upper
GI, SBS

Consultations my many
disciplines including surgeon,
transplant coordinator,
psychology, psychiatry, social
work, child life, child
development, specialist MD
Criteria for Transplant

End stage disease

Failure to treat

Benefits> Risk

absence of malignancy &
infection

Able to survive surgery

Sepsis

Loss of line sites

MELD/PELD (liver)

NORS score/rating
What is the testing for
histocompatability?

ABO and Rh

HLA - Human leukocyte or lymphocyte
antigen


Contraindication – positive tissue typing for
crossmatch with HLA antibodies
PRA - panel of reactive antibodies
Complications of Transplant

Rejection

Infection

Death

Multi-system involvement/ failure
What are the types of graft
rejection?


Hyperacute

minutes to hours


Chronic

months or years
preformed B cell antibodies
to donor antigens

T and B cell
not always treatable

Acute


4 days to 4months

treatment not usually
successful
Graft-versus- Host

with bone marrow
transplants

cell mediated

Treatable

donor T cells react

Reversible – OKT3

S&S: skin, liver, GI
HYPERACUTE REJECTION
Can
be avoided with
crossmatching prior
to transplant
What are the medications for
immunosuppression?

Imuran

inhibits DNA/RNA

blocks antibodies



cellcept or cytoxan could be
substitute
ATG

alters T cell function

serum sickness

ALG as a substitute
Thymoglobulin

Muromonab-CD3 or
OKT3

monoclonal antibody

blocks T cell function

premedicate


prevention/treatment of
rejection
cytokine release syndrome
Basiliximab-chimeric
antibody (mouse/human)
Medications continued...

Tacrolimus (fk-506)/ Sirolimus
(renal dysf)
-100 times more potent than
CSA
-Many drug interactionsNephrotoxic with NSAIDS
-Blocks interleukin 2 production

Cyclosporine
-nephrotoxic, hepatotoxic

Corticosteroids-drug
interactions!
What are the types of donor
bone marrow?

Autologous - donor is recipient, How is this
possible?

Allogenic - human with similar HLA type

Syngeneic - identical twin

Peripheral blood stem cell harvest apheresis
BM Transplantation process

Harvesting


marrow is obtained from
the posterior and anterior
iliac crests and filtered
Bone marrow infusion


Post transplant nadir period


thaw bone marrow and
infuse through an IV with a
filter

day 0 is day of transplant
and nadir point of
pancytopenia
care directed to
neutropenia,
thrombocytopenia, and
anemia (protective
isolation)
pre-engraftment
Transplantation process if
allogenic
 Conditioning
goals:



remove malignant
cells
inactivate the
immune system
empty the
marrow cavities

Nursing care related
to conditioning ( the
side effects of chemo
such as cytoxan):

alopecia

anorexia, nausea

stomatitis

SIADH

hemorrhagic cystitis
Post-engraftment period

New blood cells are circulating in peripheral
blood 2-4 weeks after transplant

Continue on Cyclosporine A and steroids

Continued protection for patient for 2-3
months
Nursing Care of the Bone Marrow
Transplant Patient

Conditions that
require BMT:

leukemia, aplastic
anemia, immune
deficiency
diseases, tumors
of the breast,
ovarian,
testicular

Why is bone
marrow transplant
important as a
treatment for
malignant disease?

Allows the client
to receive high
doses of
chemotherapy
without concerns
of
myelosuppression
Nursing Diagnoses related to
BMT

Risk for infection

PC: Bleeding

Alteration in fluid volume

Ineffective breathing pattern

Altered Sensory-perception

Altered skin integrity R/T GVHD

Impaired family/individual coping
Recipient Concerns

Pre-transplant
concerns

Maintain physical health/
current labs

Dental screening

Treat chronic conditions

Psychological preparation

Prepared every minute

Fear/ Cost

Post-transplant concerns

Potential for infection

Alteration in elimination



Knowledge deficit of health
maintenance
Increased demand of care
partner
Fatigue
Donor Concerns

Quality of Life

Criteria for being a donor

Responsibility

Support
Major Types of Transplants
and resultant nursing care

Kidney



Heart
Pancreas

Corneal

Other:

orthotopic approach

Stem cell

heterotopic approach

Bone

Skin

Small Bowel

Heart valves

Liver/Small Bowel
Heart-lung, lung


check urine output &
electrolytes

mechanical ventilation
Liver
Corneal transplant

Surgical removal of diseased cornea and replaced with donor

Use a calm approach

Assess for signs of infection prior to surgery

Regional anesthesia is used

Antibiotics injected after

Dressing in place and removed the next day by the surgeon

Pt to lie on non operative side

A shield is to be worn at nite for the 1st month

Graft rejection is possible
Liver transplant

Not candidate if: severe cardiovascular instability, severe respiratory
disease, active alcohol or substance abuser, metastatic malignant
disease, inable to follow directions regarding meds and self care

Donor livers are primarily from trauma victims

Living donors can also be used

The liver is the only organ that can grow back
Renal transplant

Not a cure

2-70 yrs is age range to get transplant

Thorough assessment before

Cardiac disease excludes candidate

Monitor urinary status closely

Cancer clients get dialysis

Diabetes clients need very close monitoring
donors

Kidney donors may be living or dead

Matching is difficult

Kidneys donors must be : free of disease and infection, no history of cancer, no
htn or renal disease, adequate renal function
Post op

Urological management is key

Monitor for rejection

Monitor urine color

Pink and bloody right after

Normal after several days-weeks

Daily specimens obtained and cultured

Instruct about meds and rejection
Heart transplant

2300 transplants each year

Criteria to get: life expectancy less than 1 year, age less than 65, normal
pulmonary vascular resistance, no active infections, stable psychosocial
status, no drug or etoh abuse

Post op: monitor for bleeding, similar recovery to cabg, monitor for
tamponade, instruct client to change position slowly b/c of orthostatic
hypotension 2nd to denervation, instruct to follow medication schedule
religiously to prevent rejection which usually happens in first 3 months,
instruct client to follow recommended diet, allow 10 minutes warm up
and cool down with exercise
Role of the Nurse in
Transplantation Issues
The nurse needs to
express caring/empathy
to client issues:

The assessment/ physical
exam

The psychosocial evaluation
6
coping mechanisms

cost
6
support systems

ethical concerns
anxiety

6
legal regulations
6
depression
6
loss of control


uniform anatomical gift
act

National Organ Transplant
Act

UNOS
Success of Transplant

Liver- 83% at 1 year/ 71% 5 year(cad)

Liver- 85% 1 year/ 81% 5 year (living)

Small bowel/ Liver-Small bowelapproximately 65% one year/ 46% 5
year

Heart- 83% at one year/ 69% 5 year

Heart/Lung- 65% at one year/41% 5
year

Kidney- 94% one year/ 82% 5 year
(cad)

Kidney- 97% one year/91% 5 year
(living)
Living Donation

Usually between 18-60 years of age

May give single kidney, lobe of lung, segment
of the liver, or portion of the pancreas

Tissue typing, crossmatching, and antibody
screen are performed, as well as urine tests,
CXR, EKG, arteriogram, and
psychologic/psychiatric evaluation
Positive Aspects of Living
Donation

Eliminates waiting list-surgery may be scheduled(decreases
stress of Tx)

Recipient may begin taking immunosup. Drugs 2 days before
transplant

Higher rate of compatibility...between blood related
living donor

Psychological benefit
Websites to Visit

United Network for Organ
Sharing (UNOS) www.unos.org

American Society of
Transplantation (AST)
www.asts.org

Nebraska Medical Center
www.unmc.edu

www.nebraskatransplant.org

Transplant Recipients
International Organization
www.trioweb.org

http://www.youtube.com/watch?v=IFSNDqjOS_8&f
eature=related