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Cancer

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amanda sherwood

on 25 November 2014

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Transcript of Cancer

Cancer
Pathophysiology:
cancer
therapies:
Treatment with agents derived from
biological sources or affecting biological
responses.
3 Mechanisms:
Increases, restores, or modifies the host defenses against the tumor
Uses agents that are directly toxic to tumors
Modifies the tumor biology
The patient and family may look forward to death as a relief from unrelenting suffering
Most patients with advanced cancer know that they are dying and show relief at being able to discuss their imminent death

Biopsy= incisional, excisional, needle aspiration
Endoscopy
Diagnostic imaging
Radioisotope studies
Computed tomography (CT)
Ultrasound testing
Magnetic resonance imaging (MRI)
Positron emission tomography (PET)
Lab and diagnostic exams
Measurement of alkaline phosphatase blood levels=
Serum calcitonin level=
Carcinoembryonic antigen serum level=
Blood markers= PSA, CA-125. CA-19-9
Stool exam for occult blood=

Lab/diagnostic tests:
Description of CA:
Risk factors:
Terminal Process:
Advanced Cancer:
• Is becoming a promising alternative to BMTs; differs from BMT primarily in the method of collection of stem cells.
• Because there are fewer stem cells in the blood than in the bone marrow, mobilization of stem cells from the bone marrow into the peripheral blood can be done using chemotherapy or hematopoietic growth factors, such as GM-CSF and G-CSF.
• Blood is removed through a process called leukapheresis
• Hematologic recovery period in PSCT is shorter with fewer, less severe complications

Peripheral Stem Cell Transplantation:
Bone Marrow Transplantation:
Biotherapy:
Surgery:
Radiation:
Chemotherapy:
Development Prevention:
Common side effects to BMRs include
 Fatigue
 Flulike symptoms
 Leukopenia
 Nausea
 Vomiting


• Nursing interventions:
 prevent infection (include protective isolation or laminar airflow rooms; prophylactic systemic antibiotic and antiviral agents)
Routine cultures of blood, urine, throat and stool
• *Survival after BMTs depends on the patient’s age, remission and clinical status at the time of the transplant.

Pain management
• • Pain is the primary symptom of 70% of people throughout the world who die of cancer each year
• Pain is almost always a late symptom and indicates tumor obstruction, pressure on the nerves, invasion of bone, phantom sensation, peripheral neuropathy and neuralgia.
• Accept the definition of pain as existing when the person experiencing the pain says it is
• Avoiding the peaks and valleys of pain relief, having fixed administration schedules, treating breakthrough pain, monitoring and treatment of any opioid side effects and use of nonopioid analgesics are important in treating terminally ill patients pain


nutritional therapy
• Most frequent nutritional problems with cancer patients are malnutrition, anorexia, altered taste sensation, nausea, vomiting, diarrhea, stomatitis, and mucositis.
• A combination of factors such as drug toxicity, effects of radiation, tumor involvement, recent surgery and emotional distress or difficulty with ingestion or digestion of food are the cause of these problems
• The patient with cancer usually experiences protein and calorie malnutrition characterized by fat and muscle depletion
• The patient may also experience an alteration in sweet, sour and salty taste sensations; advise them to avoid foods they dislike and experiment with spices/seasonings to mask taste alterations

communication and psychological support
Goal: remove all malignant cells; may include removal of tumor, surrounding tissue and regional lymph nodes
Surgery can be:
Preventative: prophylactic mastectomy
Diagnostic: polyp removal during colonoscopy
Curative: well-isolated lesion removed in early stages as in cancer of the skin, testicle, breast or cervix
Palliative: relieving symptoms such as obstruction, ulceration, and pain
Reconstructive: breast reconstruction post mastectomy
Trend towards more conservative surgical management
Laser beams: vaporizes tissue with little bleeding and low risk for infection
Nursing Interventions:
Be present when physician discusses treatment options with pt
Reinforce physician's information to pt and family and clarify explanations of tx and assess understanding
Encourage the pt to ask the physician questions about treatment and associated risks
Report any misunderstandings, unrealistic expectations, or other problems to the physician
Accept and support the pt's choice, regardless of personal opinion
External Radiation
Specific area on the body to be treated is marked to indicate the port at with the radiation will be directed
DO NOT wash off markings
Avoid using ointments, lotions or powder on area
Protect radiated area from direct sunlight
Avoid applications of heat or cold - this will increase erythematous, pruitus and dry skin
Encourage diet high in protein adn calories and fluid intake of 2-3 L/day
Lethargy and fatigue are common; educate about rest periods
Internal Radiation
Radioactive implant (brachytherapy): insertion of sealed radioactive materials temporarily or permanently into hollow cavities within body tissues or on the body's surface
Delivers a specific radiation dose continuously over hours or days
Usually combined with a course of external radiation to increase the dosage to a specific area such uterus and vagina
Radioactive needles, wires, seeds, beads or catheters may be inserted directly into tumor tissue
Unsealed internal radiation: administered intravenously or orally so that it is distributed throughout the pt's body.
Take precautions to prevent exposure to radiation from direct contact with any body tissue or fluid
Group cares together; and stand as far away from internal radiation site insertion as possible
Limit the amount of time needed for close contact near the irradiated site; wear lead apron for direct, prolonged care
Side Effects of Radiation
Early Side Effets:
Dryness, itching, blistering, or peeling of skin
Fatigue
Late Side Effects: (6 months or later)
Brain problems
Infertility
Joint problems
Lymphedema
Mouth problems
Ofosteoradionecrosis (bone death)
Secondary cancers (rare)
Goals &
Prognosis:
Used to cure or control cancer that has spread to local lymph nodes or to treat tumors that cannot be removed
Used preoperatively to reduce tumor size
Used postoperatively to destroy malignant cells not removed by surgery
Used palliatively to slow the growth of malignant tumor
Malignant cells lack the capacity for repair. More cancer cells than normal cells are damaged by radiation and normal cells are able to recover better
Normal cells do have a maximum dose of radiation they can tolerate; meticulous planning and recording of the dose are essential
Visitors
Children younger than 18 years old and pregnant women should not be allowed to visit implant patients
Approved visitors should limit visits to 10 minutes and to stand as far away from the pt as possible
What psychosocial impacts could this have on the patient?
Alopecia
Stomatitis
Nausea, Vomiting & Diarrhea
Tumor Lysis Syndrome
Leukopenia
Reduction in the # of circulating WBCs d/t depression of the bone marrow
Can lead to life-threatening infections; neutrophils most often suppressed leading to neutropenia (pt should be placed on neutropenic precautions)
Protect pt from pathogens, monitor VS and s/s of infection q 4 hrs
Use the following systemic approach to assessing the pt for infection:
Mouth
Skin
Pulmonary function
Urinary/Bowell function
Medical management
Thrombocytopenia
Anemia
Chemotherapy drugs are used to reduce the size or slow the growth of metastatic cancer
Most agents work by interfering with the cells' replication process; the drugs damage the cell and cause cellular death
Both malignant and normal cells are affected by chemotherapy
Cells that multiply rapidly are affected the most (cells of the hematopoietic system, the integumentary system and the GI system
There are many side effects d/t the destruction of normal cells in these systems (Table 17-3)
Neutropenic Precautions:
Monitor fever and neutrophil count to identify signs/potential for infection
Evaluate for chills (fever may be the only sign of infection and septic shock) and take VS q 4 hrs
Report temp >100.4 F (38 C)
Institute good hand hygiene, place pt in private room, limit/screen visitors and healthcare workers with potentially communicable illnesses
Teach pt necessary personal hygiene techniques
Avoid invasive procedures
Administer hematopoietic growth factors to increase pt's WBC count
Neutropenic diet: avoid fresh fruits and vegetables
Discourage fresh flowers or live plants in the room
•• The patient and/or family may become irritable and angry with caregivers; understand that these feelings are not directed toward the caregivers personally but have emerged from the circumstances associated with the patients disease
• A positive attitude by patient, family and caregiver toward cancer and tx has a significant positive effect on the quality of life that the patient experiences.
• Coping with fears exposes the patient to a range of emotions and behavioral patterns, which may occur at any time during the process of cancer.


Loss of hair d/t the destruction of hair follicles
Occurs by two mechanisms:
If the hair roots are atrophied, alopecia occurs rapidly; hair usually falls out in large clumps
If the hair shaft if constricted because of atrophy or necrosis the hair will break off near the scalp leaving the root and a patchy thinning pattern occurs
Hair loss occurs on other parts of the body esp. the eyebrows and eyelashes
Pattern and extent of heir loss cannot be accurately predicted for each pt, hair loss can occur within a few days to a few weeks of treatment, hair growth may return while chemotherapy still continues
Color and texture may change when hair grows back
Reduction of RBCs and hemoglobin d/t depression of the bone marrow
Hemoglobin Levels:
10-14 g/dL = mild anemia
6-10 g/dL = moderate anemia
<6 g/dL = severe anemia
Anemia causes fatigue because of decreased oxygenation to tissues
Balance activities with rest periods to prevent hypoxemia
Recombinant human erythropoietin or epoetin alfa (EPO; Epogen, Procrit) initially was approved by the FDA for tx of anemia in end-stage renal disease but the FDA expanded to include management of chemotherapy-related anemia in 1993
Given subq or IV
Transfusion of packed RBCs is indicated if there is evidence of cardiac decompensation of if low hemoglobin levels are combined with low platelet counts
Reduction in the # of circulating platelets d/t depression of the bone marrow
When platelet count is <20,000/mm3 spontaneous bleeding can occur - platelet transfusions may be necessary
Pt teaching to prevent injury:
Soft toothbrush or swab; avoid rectal medications or enemas; use electric shaver; apply direct pressure 5-10 min if bleeding occurs; avoid contact sports, elective surgery or tooth extraction; avoid picking or blowing forcefully; avoid trauma; avoid ASA; use adequate lubrication and gentleness during sexual intercourse
Mouth inflammation d/t destruction of normal cells of the oral cavity
Ranges from erythema of the oral mucosa to mild or severe ulceration
May develop a superimposed fungal infection of the mouth and esophagus
Tx= oral nystatin or fluconazole
Chemotherapeutic drugs that cause stomatitis: Methotrexate, doxorubicin, dactinomycin, bleomycin and 5-fluorouracil
TEACH GOOD MOUTH HYGIENE!
Xylocaine used when stomatitis becomes intolerable - light topical application allows pt to eat (soft or liquid diet) and drink
Caused by the excessive breakdown of normal GI cells
Among the most uncomfortable and distressing side effects of chemotherapy
Onset and duration vary with each patient and drug given
May interfere with daily activities, cause fluid and electrolyte imbalance, general weakness and weight loss
Decline in nutritional status increases risk for infection, decreases tolerance to therapy and predisposes pt to depression and withdrawal
Every effort must be made to minimize chemo-induced N/V
Antiemetics vary in sucess; Tetrahydrocannabinol (THC) work on some pts who have not benefited from commonly prescribed antiemetics (Reglan, Zofran, Kytril)
Ativan relaxes and make the pt less sensitive to N/V
Changes in bowel habits usually do not require intervention but if persistent diarrhea occurs Lomotil may be prescribed
Etiology/Patho
May occur spontaneously in pts with inordinately high tumor burdens; however it is usually a result of chemotherapy or, less commonly, radiation
May occur anywhere from 24 hrs to 7 days after antineoplastic therapy is initiated
Pts most at risk are those who: have large tumor cell burdens, or markedly elevated WBC levels (acute leukemias), chronic lymphocytic leukemia and metastatic breast cancer
Develops when the destruction/lysis of a large # of rapidly dividing malignant cells causes intracellular contents to rapidly release into the bloodstream
This causes: hyperkalemia, hyperphosphatemia and hyperuricemia with secondary hypocalcemia
Pt is at risk for renal failure and alterations in cardiac function
Clinical
Manifestations
Early signs: N/V, anorexia and diarrhea
May be accompanied by muscle weakness and cramping
Later signs: tetany, paresthesias, seizures, anuria and cardiac arrest
Diagnostic Tests
Dx by observation of the s/s and by confirmation of abnormal laboratory values of serum potassium, phosphate, calcium and uric acid
Other important values include: serum creatinine, blood urea nitrogen and urine pH
Early symptoms of TLS may not be readily apparent; lab values should be monitored closely
Medical
Management
The best tx is prevention by prophylactic measures in those identified as high-risk. This includes:
Hydration: maintain urinary output of 150 mL/hr; begun 24-48 hrs prior to tx and continued for at least 72 hrs post tx
Allopurinol: prevents uric acid formation, begun a few days prior and continued 3-5 days after tx
Sodium bicarbonate: used to maintain an alkaline urine to prevent uric acid crystallization
Calcium gluconate: given IV to correct hypocalemia
Cardiac monitoring is required
Kayexalate (binds with potassium) and aluminum hydroxide (binds with phosphorus) helps excretion through the bowel
If these measures are unsuccessful renal dialysis may be necessary
Nursing Interventions
Identifying pts at risk for TLS and implementing prophylactic measures
Assess medications for those containing phosphate or spare potassium and discuss discontinuation with physician
Assess pt for s/s of TLS
Monitor I & Os and notify physician if urine output is less than 100 mL/hr
Monitor pH of urine and maintain >7 with sodium bicarbonate
Prepare pt for dialysis if needed
Prognosis
Success depends on preventing renal failure
Usually resolves within 7 days once appropriate tx is initiated

TLS is an oncologic emergency with rapid lysis of malignant cells
Side effects of Chemotherapy treated with:
Prognosis
Antiemetics (Reglan, Compazine, Kytril, Zofran)
Antidiarrheal (Lomotil)
Opioid analgesics (Morphine, Dilaudid)
Antiinflammatory (Naproxen, Decadron)
Antihistamine (Benadryl)
Antianxiety (Ativan)
Antidepressants (Elavil)
See Table 17-4
Chemotherapy has proven effective in tx of many cancer pts, whereas others experience cancer-free intervals or control of pain
Learn about each drug (Table 17-3) being administered to anticipate the expected side effects and plan interventions needed
Follow safety guidelines in preparing and administering chemotherapeutic agents because they may be absorbed into the skin or inhaled
Remind pts that some of the problems they are experiencing are the result of therapy and not a sign that the cancer is getting worse
• Is the process of replacing diseased or damaged bone marrow with normally functioning bone marrow.
• Autologous vs Allogenic (synergeneic, related or unrelated)
• These patients are at a higher risk for infection during the transplant process and are thus cared for in special bone marrow units

short-term goals
Pt's will set up a daily routine that lets them be active when they feel their best.
Pt's will keep things they use often within easy reach to save energy.
Pt's will use relaxation and visualization techniques to reduce stress.
Long-term Goals
Pt's will establish a support group and ask for help when they need it.
Pt's will get regular, light to moderate intensity exercise.
Pt's will recognize and reward their achievements.
hospice
care
•Focused on enhancing the patients quality of life not prolonging it
•Provides skilled professional care and voluntary support services that assist the patient and family in living life to the fullest each day.
Prognosis:

Varies individually depending on patients overall
health, location, stage and treatment.

If cancer is too advanced or untreatable it
can be fatal.
normal
Basic unit of structure and function=cell
60,000 billion cells in the adult human body
Need nutrients (oxygen, gat, protein, carbs) to survive. Change into energy
Cells reproduce. Only make enough to replenish
Body destroys abnormal cells
abnormal
Cancer develops when cells don’t recognize abnormal cells
Not differentiated or recognizable as being same size or shape as normal cells
Cancer cells divide and multiply, but aren’t limited like normal cells to meet body’s needs
Local increase in number of cells, lose normal cellular arrangement, shape and size vary, increase miotic activity, abnormal mitosis and chromosomes

Non-neoplasm= abnormal cell growth, not always cancerous but could precede to develop to cancer.
Hypertrophy=increase in the volume of an organ or tissue due to enlarged cells
Hyperplasia=increase in number of cells
Metaplasia=cells change in form
Dysplasia= bad/difficult formation
Anaplasia= “without form”. Irreversible change
Neoplasm= uncontrolled or abnormal growth of cells
tumors= swelling/enlargement. Localized or invasive.
Benign= not recurrent or progressive, non cancerous
Malignant= growing worse, resisting treatment, cancerous growth
Table 17-2 on page 785

Metastasis= process by which tumor cells spread from primary site to a secondary site
Occurs by
direct spread of tumor cells by diffusion to other body cavities or
circulation by way of blood and lymphatic channels
Carcinogenic factors, some viruses, certain genetic factors could be predisposition to cancer
Weakened immune system caused by cancer-producing substances, tumor cells and the aging process
Immunosurveillance= T-cells are responsible for detecting abnormal cells, recognize and destroy
Malignant cell carries a tumor-specific antigen on its membrane, which normally a t-cell recognizes it as abnormal and destroys it
If T-cells function is suppressed; by age, drugs (corticosteroids), poor nutrition, alcohol, serious infections, certain diseases; then risk for cancer increases

No other medical diagnosis produced as much fear as a diagnosis of cancer. Cancer is more
It's more feared than heart disease.
The word cancer is viewed as synonymous with death, pain and disfigurement. However, attitudes toward cancer have not kept pace with advances in the treatment and control of cancer.
Of every five deaths in the United States one is from cancer, making it the second leading cause of death (heart disease is the most common).
Overall, it affects all ages, but most cases (76%) are diagnosed in those over the age of 55. An
estimated 30% of Americans now living will experience cancer at some point in their lives.
In 2006, 564,830 Americans died from cancer, which is more than 1500 persons per day.
Cancer rates have been decreasing since 1991 in men and since 1992 in women. The 5 year survival rate is now 65%.


Oncology is the sum of knowledge about tumors; it is the branch of medicine concerning the

study of tumors. Oncology nursing is the care of people with cancer.
Prevention and early detection of cancer includes recognition of cancer’s warning signals, preventive behaviors and screening test.
The nurse plays a prominent role in prevention and detection of cancer. Early detection and prompt treatment are directly responsible for increased survival rates.
Beginning in high school, all women should be taught to perform breast self examination each month.
Males, beginning at puberty, to check the scrotum for enlargement, thickening, or the presence of a lump in the testicles.
Men over 50 should have a prostate­specific antigen (PSA) test and rectal examination once a year.
Exercise regularly at least 30 minutes for 5 or more days.
Obtain adequate periods of rest, at least 6 to 8 hours per night.
Have a health examination on a regular basis.
Eliminate, reduce, or change the perceptions of stressors and enhance the ability to effectively cope with stressors.
Enjoy consistent periods of relaxation and leisure.
Seek immediate medical care if you notice a change in what is normal for you.
Nurses unique role in pain management involves acting as a link between the patient and the health care team; spending time with the patient; assessing the patients response to pain and its management; educating the patient and family; be able to articulate as well as anticipate and address the patients, families and health care providers misconception of pain management
Encouraging the use of patient self-control methods and self-care measures•
• Ensuring that patients are not subject to severe suffering from potentially controllable pain

Nurses need to encourage patients to eat protein rich high calorie foods, suggest to the physician the need for nutritional supplements, monitor albumin et prealbumin levels, et use enteral or parenteral nutrition as adjunct nutritional measures as needed
As nurses we need to be available especially during difficult times, maintain a relationship based on trust and confidence, be open, honest and caring in our approach and assist the patient in setting realistic, reachable short and long-term goals.
Nurses are able to make cancers effects less traumatic through sensitivity and creativity; understand how each patient needs a sense of control; encourage and provide as many avenues of control as possible and talk to the patients as people/friends not as patients.
Arise from germline mutations, often several relatives have the same or related cancers. They are more likely to be bilateral, and the same person may have multiple cancers. They are often seen in unusual organ combinations.
Only 10% of cancers have an etiology of a strong genetic link.
The following patterns have emerged.
The incidence of postmenopausal breast cancer is three times higher and five times higher if you have a family history.
Of all women who develop breast cancer 95% do not carry the genes BRCA1 or BRCA2.
The incidence of lung cancer is greater in smokers with a family history of this disease.
The incidence of leukemia is greater in an identical twin of a person with the disease.
Neuroblastoma occurs with increased frequency among sibling.
Colon cancer is more likely to occur in women who have a history of breast cancer.
When someone is suspected of having a mutation, a cancer risk assessment is performed.
Genetic counseling is an essential component of the genetic evaluation.
cancer
PREVENTION AND EARLY DETECTION
Nurses need to be honest and open with patients and family
•The nurses major role at the hospital is teaching the patient and at least one family member or significant other how to continue any special care needed at home
•Promote self-care to the greatest extent possible
Described according to the original site of a primary tumor
Tumors are usually named for its location, cellular makeup, or by the person who identified the particular type
ex: adenocarcinoma(adenoids), chrondroma(cartilage), erythroblastoma(red blood cells)
Carcinoma-composed of epithelial cells (skin, glands, mucous membrane linings)
Sarcoma-composed of connective tissue (muscle, cartilage, bone, fat)
Lymphoma-composed of lymph nodes and tissue
Leukemia-composed from immature blood cells grown in bone marrow

Grading
Tumors are graded by their degree of malignancy. 1-4
Grade 1 is the most differentiated and least malignant
Grade 4 is least differentiated and most malignant

Staging
Staging determines the extent of the disease process. Stage 0-IV
Stage 0: cancer in situ (not quite cancerous, hasn’t spread to other tissues)
Stage I: tumor limited to the tissue of origin; localized tumor growth (cancerous, but hasn’t spread yet)
Stage II: limited local spread (cancerous that has spread to local tissue)
Stage III: extensive local and regional spread (cancerous that has spread to most local tissues and throughout some organs of the body)
Stage IV: metastasis (cancerous that has spread throughout the other organs of the body)

TNM
Classification
Box 17-2 on page 786
Determines the extent of the cancer according to 3 parameters
Tumor size (T)
Degree of regional spread to lymph nodes (N)
Metastasis (M)
Used to direct treatment, predict prognosis, and contribute to research

Preferred system of reading results, most common with pap smears
Exfoliative cytology= studying of cells that the body has shed during normal growth and replacement
Results:
Negative
Probably negative
Suspicious, but not conclusive for malignancy
More suspicious, strongly suggestive of malignancy
Conclusive for malignancy

Bethesda system
Cancer’s seven warning signals

Changes in bowel or bladder habits
A sore that does not heal
Unusual bleeding or discharged
Thickening or lump in breast or elsewhere
Indigestion or difficulty swallowing
Obvious change in warts or moles
Nagging cough or hoarseness
ONCOLOGY
tnm staging
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