Transcript Chapter 10 Nursing Care of Patients with Cancer

Nursing Care of Patients
with Cancer
Review of Normal
Anatomy and Physiology

What is Cancer?

By definition:
Excessive growth of cells that lack
capabilities of normal cellular function.
Cancer is a name for a large group of
diseases characterized by cells that
multiply rapidly, are uncontrolled, and
invade normal tissue.
Cell Cycle

 Normal cells- When cells reach life expectancy, they
reproduce to form new cells as the body needs them.
Cells of the same type reproduce until the correct
number have been replenished. Cell division stops when
normal cells surround other normal cells.
 Cancer cells- new cells form when the body don’t need
them and the cells don’t die when they should. These
extra cells form a mass of tissue called a tumor. They
ignore the growth regulating signals around them. They
continue to grow in a disorderly , unrestricted manner.
Predisposing factors are to blame.
Cell Cycle
Cancer

Oncology is the specialty area that
deals with cancer patients. AKA: the
study of tumors.
Cancer is the second leading cause of
death in the U.S.
Early detection and treatment is vital in
the successful treatment of cancer.
Cancer Concepts

Neoplasm- new growths of abnormal
tissue. Not all neoplasms contain cancer
cells. 2 types of neoplasms exist:
Benign- non-cancerous cells, non
recurrent.
Malignant- cancer cells that are
unlimited in growth. Growth
continues until cells start to break off,
which leads to metastasis.
Benign Tumors

Slower rate of growth
Localized
Generally remain encapsulated
Movable and well defined
Cells resemble those of origin
Recurrence is rare
Usually not life threatening
Malignant Tumors

 Rapid rate of growth
 Invades surrounding tissue or metastasizes
 Rarely encapsulated
 Irregular borders and immovable
 Cells can’t be readily identified as to tissue of
origin
 Recurrence is common
 Fatal if not treated
FACTS

An organ containing a benign tumor can
usually go on and function as usual without
complications- unless size interferes with
function.
Breast lump or ovarian cyst
An organ containing a malignant tumor will
eventually be affected and it’s function will
be altered.
Lung CA- SOB, coughing, hemoptysis
Metastasis

The spread of a tumor from the primary site
to a different area or distant part of the body.
“In situ” simply means that a tumor is
contained within one area. AKA: localized
In situ tumors are usually surgically removed
and may or may not require treatment.
If a tumor metastasizes, there are more
general effects on the body.
Metastasis

Mets can occur by three means
Invade blood or lymph vessels
Move by mechanical means
Lodge and grow in a new location by
direct extension into surrounding tissues
Etiology

Cancer cell growth involves a 2-step process
Initiation- normal cells become altered or
damaged due to carcinogen exposure.
Define carcinogens/carcinogenesis.
Promotion- repeated exposure to
carcinogens that causes cells to mutate.
Risk Factors

Viruses
Radiation
Chemicals
Irritants
Genetics
Diet
Hormones
Altered
Immunity
Cancer Types/Tumor
Classifications

4 types of malignant tumors:
Carcinoma- originate from epithelial cells
and tend to metastasize
Sarcoma- originate from connective tissue
Leukemia- originate from organs that form
blood
Lymphoma- originate from organs that fight
infection
Viruses

Retrovirus- often found in leukemic cells
Epstein-Barr virus- associated with
lymphoma
HSV 2- associated with cervical and penile
cancers
HPV- associated with cervical and penile
cancers
Hepatitis B- associated with liver cancer
Radiation

Sunlight- leading cause of skin cancer
and leukemias. U/V rays.
Radiation leaks
X-rays
Prolonged exposure to power lines,
electromagnetic waves such as cell
phones and microwaves
Chemicals and Irritants

Length of exposure and degree of
exposure play a role.
Tobacco- leading cause of mouth and
throat cancers. Also contributes to lung
CA.
Chemicals used in factories
Alcohol intensifies toxicity of tobacco
Asbestos
Genetics

Accounts for only 10% of cancers!
Cancers associated with genetics
Breast CA
Skin CA
Colon CA
Leukemia
Genetic screening and counseling is available
Ex: BRCA 1 and 2
Diet

What a person does not consume is as
important as what he or she consumes!
High-fat, low-fiber diets predispose to
CANCER
Diets low in vitamins C,A, and E
predispose to cancer
Hormones

Estrogen is associated with cancer of
the breast, uterus, ovaries, cervix and
vagina.
The estrogen/progesterone sensitivity
plays a big role in the treatment of
breast cancer. (ER/PR) If this test is
positive, the patient will have to do
Herceptin long-term or for remainder
of life.
Adenocarcinoma of the Caecum

Lung Cancer
Metastasis to Skin
Most Common Cancers
 Men
 Prostate
 Lung
 Colon
 Women
 Breast
 Lung
 Colon
Cancer Death Rates

Warning Signs of Cancer

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/other tissue
I-indigestion or swallowing difficulties
O-obvious change in wart or mole
N-nagging cough or hoarseness
Prevention

Early Detection
Regular Screening
Genetic Testing
Healthy Lifestyle
Prevention (cont’d)

Protectant Foods
Folic Acid
Omega-3 Fatty Acids
Fruits and Vegetables
Vaccines
Incidence

The exact cause of cancer is unknown
Highest incidence in ages 60-69
Followed by 70-79
Men have a higher incidence of cancer that
women
Mortality rates have decreased
Remission
Partial
Complete
Diagnosis

Biopsy
Lab/tumor markers
Cytology
Radiological tests
Nuclear imaging
Ultrasound
MRI
Endoscopic procedures
Fine Needle Biopsy
Stereotactic Biopsy
Mammogram
Staging of Cancer

Treatment of cancer is based on staging of disease.
 Tumor, Node, Metastasis system (pg. 178)
◦ T is for tumor size
◦ N is for node involvement
◦ M is for metastasis or extent thereof
◦ Ex: T2, N1, M0
 Staging system
◦ Stage I
Stage III
◦ Stage II
Stage IV
Cancer Treatment
Options

Surgery
Curative
Palliative
Other-Prophylactic
Other-Reconstruction
Radiation Therapy
Chemotherapy
Side Effects of Radiation

Fatigue
Nausea, Vomiting, Diarrhea, and Anorexia
Mucositis
Xerostomia
Skin Reactions
Bone Marrow Depression
Radiation

 Radiation can be one of two types
 Internal- allows for higher doses without
destroying surrounding tissues. Radiation is
actually emitted from pt during therapy.
Safety principles apply.
 External- external beam radiation to destroy
cancer cells with minimal damage to normal,
healthy cells.
Internal Radiation Therapy

Unsealed- administered
IV or oral
 Distributed throughout
pt’s body
 Use safety precautions
when in direct contact
with patient and or any
body tissue or
Sealed- administered
into hollow cavity
 Delivers specific rad.
dose continuously over
hours or days
 Radiologist inserts and
removes
 Can be used for cervical
cancer, uterine cancer,
prostate cancer
Radiation Safety:
Internal
Time- Plan ahead by having everything
needed when entering pt room
Distance- Stand at the greatest distance
away from site of internal radiation
Shielding- Wear lead apron if close
contact and prolonged care are needed
Radiation Safety:
Internal

 Visitors are limited to
10 min. standing as far
away from radiation as
possible
 Prevent dislodgement
of sealed implant from
cavity through strict
bed rest with minimal
turning from side to
side
 Radiation in Use sign
on door
 If vaginal radiation
implant, keep legs
closed together and
straight
 Do not bathe patient
below the waist
 Low residue diet to
minimize BM which
could cause
dislodgement
Radiation Safety:
Internal Cont.

 Force fluids
 Check position of
 Foley cath will be in
place to keep bladder
from being exposed to
radiation and b/c of
bedrest
 Do not raise HOB more
than 30 – 45 degrees
 TED hose
 Keep long handled
forceps and a lead
container in pt’s room
applicator every 4
hours by checking
threads that are
brought out and
fastened to the skin
 Implants are inserted
by Radiologist – if
implant fall out, CALL
RADIOLOGIST TO
PUT BACK IN!!!
NEVER TOUCH
IMPLANT
Radiation Safety:
Internal – After implant
Removal

 Perform good peri-care – often times a douch and enema
are ordered
 Pt is no longer radioactive
 It is normal for patient to have odorous, discolored
vaginal discharge
Anti-Neoplastic Drugs

Anti-neoplastic drugs are drugs used in
the treatment of cancer.
They have 3 uses:
Cure
Control
Palliation
Nursing Assessment

 Things to look for in the assessment of the cancer
patient
 Side effects of chemo and/or radiation
 Sepsis, bone marrow suppression or depression, and
infection
 Signs of bleeding due to low platelet count
 Pain
 VS and weight
How Chemo Works

Chemotherapy affects cells that rapidly
divide and reproduce.
Cancer cells are not the only cells that are
rapidly-dividing cells.
ALL malignant cells must be destroyed in
order for the cancer to be cured.
Repeated cycles of chemo are needed in order
to obtain total destruction.
Can be given alone or in combination
regimens.
 Chemo is given in a series of cycles to allow for
recovery of the normal cells and to destroy more of
the malignant cells. Each cycle gets some cancer cells,
but not all. That’s why repeated cycles are needed: in
hopes that eventually all cells will be killed. Most
regimens are every 3 weeks. Some treatments can go
on indefinitely until remission or progression occurs.
Most regimens call for 6-8 week cycles or treatments
with scans ordered half way through to check
response. Cycles are utilized to give blood counts a
chance to build back up
 Nadir is a term used when patients are undergoing
chemo. Nadir means low point. This is the point
where RBC, WBC, and PLT counts start dropping.
Usually 7-10 days after start of chemo round
 Better results are usually achieved with combination
therapy vs. single agent
Classes of Anti-neoplastic
Drugs

Alkylating agents
Antibiotics
Antimetabolites
Hormones
Vinca alkaloids
The common goal of all classes is to attack
and kill cancer cells!!!
Nursing Management of
the Pt Receiving Chemo

Relevant factors
Drug or drugs to be given
The dose of the drugs
Patient’s physical condition
Response of the tumor to treatment
Type and severity of side effects
Pretreatment labs
Anti-neoplastic
Preparation

Strict guidelines for mixing these
agents
Must wear disposable, plastic gloves,
and gown
Prevent accidental spills
Must wash hands before and after
mixing or handling
Double or triple check accuracy
Anti-neoplastic
Administration

Chemo can be given
PO
IV (drip, push, or infusion)
SQ
IM
Intracavity or Intrathecal
Side Effects of
Chemotherapy

Bone marrow depression- neutropenia,
anemia, thrombocytopenia
Nausea, vomiting, anorexia, diarrhea,
constipation
Stomatitis
Alopecia
Possible sterility
Neuropathy
Chemo Side Effects

Alopecia
Usually occurs 10-21 days after initiation
of chemotherapy
Always inform patient of this SE
Hair loss is a personal problem that is
dealt with in varying degrees
Be supportive
Hair loss is temporary
 Hair follicles are rapidly dividing cells.
Antineoplastic medications may or may not cause
hair loss. Always let pt know alopecia is temporary
and it will grow back. Usually the hair grows back a
different color or texture. Warn the pt. that hair loss
can be gradual or come on suddenly in large
amounts. Advise pt to get a wig before hair falls out
to match the color and style. Some people have
compromised tx before due to hair loss issues.
 Ice caps may help prevent loss due to freezing hair
follicles
Chemo Side Effects

Anorexia
Helpful hints to lessen loss of appetite
Small, frequent meals
Diet high in nutritive value
Medications can be given to stimulate
appetite
Advise supplements (Ensure, Boost)
Chemo Side Effects

Bone Marrow Depression
When production of blood cells is
decreased.
Manifested by abnormal lab results and
clinical evidence often times
Neutropenia
Thrombocytopenia
Anemia
Chemo Side Effects

 Nausea and vomiting
 The most dreaded side effect
 Anti-emetics have come a long way
 Teaching should include:
 Small, frequent meals
 Fluids between meals
 Avoid greasy or spicy foods and odorous foods
 Bland diet better tolerated
 Carbonated drinks may help relieve nausea
Chemo Side Effects
 Stomatitis

 Inflammation of the mouth
 Distinguish inflammation from thrush
 Teaching should include:








Avoid cold or hot liquids
Avoid citrus or acidic juices
Avoid alcohol or smoking
Avoid spicy foods
Avoid commercial mouthwash
Encourage soft bristle toothbrush
Swish with baking soda, salt, and water soln
Medication for pain
Chemo Side Effects

Sepsis
Always a potential with significant BM
depression
A temp of 101 or greater should always be
reported
Antibiotics are prescribed if counts too low
along with drugs to raise WBC
Possible hospitalization
Patient Teaching

 Patient and family teaching when oral therapy is
prescribed
 Do not take OTC’s without prior approval
 Never increase, decrease, or omit dose without speaking
to physician. Take as directed.
 Contact physician for any problems
 Assess mouth daily and report problems
 Drink plenty of fluids
 Keep all appointments
 Alcohol only in moderation
 No invasive procedures without prior approval
 Have blood checked as ordered, on time
Chemotherapy
Extravasation
Cancer Related Pain

Pain is a major concern for cancer pts
Chronic pain can lead to depression and even
suicide
Obstacles to proper pain management
Fear of addiction
Lack of knowledge regarding pain
management (breakthrough pain)
Respiratory depression or over-sedation
Hospice Care For Advanced
CA

Most patients with advanced cancer know they
are dying. Honesty and openness are the best
approaches.
Prognosis of <than 6 Months
Goal is to keep patient comfortable
All curative treatment ceases
Promotes comfort and quality of life
Don’t forget stages of grieving/death and dying
Other Treatment
Options

Bone Marrow transplant- process of
replacing diseased BM with normally
functioning BM
Graft vs. host
Biotherapy
Also known as immunotherapy
Peripheral Stem Cell transplant-based on the
theory that circulating stem cells are capable
of repopulating the BM
Bone Marrow
Transplant

 Pt is given high doses of chemo to kill the pt’s bone
marrow. That is then replaced with healthy marrow
from a compatible donor. Bone marrow is taken from
the donor, then transfused into the pt’s blood stream.
 Until the marrow takes hold (2-4 weeks), the pt has
no immune system.
 High mortality rate with transfusions and if rejection
occurs, it’s a very painful death. The first 3 months
are critical
Oncological
Emergencies

Superior Vena Cava Syndrome- most
common in lung cancer patients.
Tumor enlarges and blocks blood flow
thru the vena cava.
S/S- very high pitched voice, edema of
head and neck, possible seizures
Hospitalization is required with
radiation therapy and drug therapy to
shrink tumor
Oncological
Emergencies

 Spinal Cord Compression- seen most in patients
with bone metastasis to the spine.
 S/S- severe low back pain and most often the loss of
the use of their legs.
 MRI often ordered to rule out compression
 Radiation required to relieve the compression of the
spinal cord
Oncological
Emergencies

 Hypercalcemia- most often seen in patients with
bone metastasis
 S/S- calcium level is over 11, confused, disoriented
 Calcium leaves the bone due to bone disease and
deterioration and enters the circulation.
 Treatment involves drugs Aredia or Zometa which
help decrease Calcium levels in the blood. Calcium
levels are checked daily. Calcitonin injections can
also be used and given by home care
 If calcium level gets too high, pt can go into a coma
Oncological
Emergencies

 Pericardial effusion- fluid around the heart
 Usually seen when the cancer invades the pericardial
sac
 S/S- SOB, edema
 Treatment is a pericardialcentesis
Oncological
Emergencies

 Disseminated intravascular coagulation (DIC)abnormal coagulation- very critical situation
 All clotting factors are used up
 S/S- bleeding, clots, infarctions
 Treatment- Fresh frozen plasma