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Nursing Care of the Client with Cancer

Nursing Care of the Client with Cancer. Cancer Background A. Definition 1. Family of complex diseases 2. Affect different organs and organ systems 3. Normal cells mutate into abnormal cells that take over tissue 4. Eventually harm and destroy host

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Nursing Care of the Client with Cancer

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  1. Nursing Care of the Client with Cancer • Cancer Background A. Definition • 1. Family of complex diseases • 2. Affect different organs and organ systems • 3. Normal cells mutate into abnormal cells that take over tissue • 4. Eventually harm and destroy host • 5. Historically, cancer is a dreaded disease B. Oncology • 1. Study of cancers • 2. Oncology nurses specialize in the care, treatment of clients with cancer

  2. Nursing Care of the Client with Cancer • Incidence and Prevalence • 1. Cancer accounts for about 25% of death on yearly basis • 2. Males: 3 most common types of cancer are prostate, lung and bronchial, colorectal • 3. Females: 3 most common types of cancer are breast, lung and bronchial, and colorectal

  3. Nursing Care of the Client with Cancer • Risk factors for cancer: (some are controllable; some are not) • 1. Heredity: 5 – 10% of cancers; documented with some breast and colon cancers • 2. Age: 70% of all cancers occur in persons > 65 • 3. Lower socio-economic status • 4. Stress • a. Leads to greater wear and tear on body in general • b. Type C personality (“cancer personality”) persons who tend to others’ needs to exclusion of their own • 5 Diet: certain preservatives in pickled, salted foods; fried foods; high-fat, low fiber foods; charred foods • 6. Occupational risk: exposure to know carcinogens, radiation, high stress • 7. Infections, especially specific organisms and organ (e.g. papillomavirus causing genital warts and leading to cervical cancer) • 8. Tobacco Use: Lung, oral and laryngeal, esophageal, gastric, pancreatic, bladder cancers • 9. Alcohol Use: also tied with smoking • 10. Sun Exposure (radiation) e.g. skin cancer

  4. Nursing Care of the Client with Cancer • Nursing role includes health promotion to lower the controllable risks 1. Routine medical check up and screenings 2. Client awareness to act if symptoms of cancer occur 3. Screening examination recommendations by American Cancer Society; specifics are made according to age and frequencies • a. Breast Cancer: self-breast exam, breast examination by health care professionals, screening mammogram • b. Colon and Rectal Cancer: fecal occult blood, flexible sigmoidoscopy, colonoscopy • c. Cervical, Uterine Cancer: Papanicolaou (Pap) test • d. Prostate Cancer: digital rectal exam, Prostate-specific antigen (PSA) test

  5. Nursing Care of the Client with Cancer • Physiology of Cancer A. Background 1. Normal Cell Growth includes two events • a. Replication of cellular DNA • b. Mitosis (cell division) 2. Four Phases of Cell Cycle • a. G1: Gap 1 Phase; cell enlarges, synthesizes proteins to prepare for DNA replication • b. Synthesis (S) Phase: DNA replicates and chromosomes duplicate • c. G2: Gap 2 Phase: cell prepares for mitosis • d. Mitosis M Phase: mitosis occurs with 2 copies of cell (daughter cells) • e. G1 or G0 phase: resting phase

  6. Nursing Care of the Client with Cancer • 3. Cell cycle is under control of cyclins which control process by working with enzymes; some cyclins “brake” (stop) the cellular division • 4. Forms the basis of how some chemotherapeutic agents work against cancers • 5. Differentiation: normal process occurring over many cell cycles for special tasks

  7. Nursing Care of the Client with Cancer a. Some unproductive differentiations occur (seen on biopsy reports) • 1. Hyperplasia: increase in number or density of normal cells • 2. Metaplasia: protective response to adverse conditions • 3. Dysplasia: loss of DNA control over differentiation (e.g. changes in cervical cells in response to continued irritation) • 4. Anaplasia: regression of cell to immature or undifferentiated cell type b. Hyperplasia, metaplasia, and dysplasia are all reversible

  8. Nursing Care of the Client with Cancer • Theories of Carcinogenesis (what causes cancer to occur) 1. Cellular Mutation • a. Cells begin to mutate (change the DNA to unnatural cell reproduction) • b. Three stages: initiation, promotion, progression • c. Example: cells mutate after years of smoking: lung cancer 2. Oncogenes/Tumor Suppressor Genes Abnormalities • a. Oncogenes are genes that promote cell proliferation and can trigger cancer • b. Tumor suppressor genes normally suppress oncogenes 3. Exposure to Known Carcinogens • a. Act by directly altering the cellular DNA (genotoxic) • b. Act by affecting the immune system (promotional)

  9. Nursing Care of the Client with Cancer 4. Viruses (weaken immune system or cause malignancies) 5 Drugs and Hormones • a. Sex hormones often affect cancers of the reproductive systems (estrogen in some breast cancers; testosterone in prostate cancer) • b. Glucocorticoids and steroids alter immune system 6. Chemical Agents • a. Industrial and chemical • b. Examples: hydrocarbons in soot ; arsenic in pesticides; chemicals in tobacco 7. Physical Agents • a. Exposure to radiation • b. Example: nuclear power plant accidents

  10. Nursing Care of the Client with Cancer • Neoplasms: also called tumors (mass of new tissue that grows independently of surrounding organs 1. Types of neoplasms a. Benign • 1. Localized growths respond to body’s homeostatic controls • 2. Encapsulated • 3. Stop growing when they meet a boundary of another tissue • 4. Can be destructive b. Malignant • 1. Have aggressive growth, rapid cell division outside the normal cell cycle • 2. Not under body’s homeostatic controls • 3. Cut through surrounding tissues causing bleeding, inflammation, necrosis (death) of tissue

  11. Nursing Care of the Client with Cancer • Malignant tumors can metastasize a. Tumor cells travel through blood or lymph circulation to other body areas and invade tissues and organs there. • 1. Primary tumor: the original site of the malignancy • 2. Secondary tumor (sites): areas where malignancy has spread i.e. metastasis (metastatic tumor) • 3. Common sites of metastasis are lymph nodes, liver, lungs, bones, brain • 4. 50 – 60 % of tumors have metastasized by time primary tumor identified b. Cancerous cells must avoid detection by immune system

  12. Nursing Care of the Client with Cancer 3. Malignant neoplasms can recur after surgical removal of primary and secondary tumors and other treatments 4. Malignant neoplasms vary in differentiation. • a. Highly differentiated are more like the originating tissue • b. Undifferentiated neoplasms consist of immature cells with no resemblance to parent tissue and have no useful function 5. Malignant cells progress in deviation with each generation and do no stop growing and die, as do normal cells 6. Malignant cells are irreversible, i.e. do not revert to normal 7. Malignant cells promote their own survival by hormone production, cause vascular permeability; angiogenesis; divert nutrition from host cells

  13. The steps of metastasis

  14. Nursing Care of the Client with Cancer • Effects of Cancer 1. Disturbed or loss of physiologic functioning, from pressure or obstruction • a. Anoxia and necrosis of organs • b. Loss of function: bowel or bladder obstruction • c. Increased intracranial pressure • d. Interrupted vascular/venous blockage • e. Ascites • f. Disturbed liver functioning

  15. Nursing Care of the Client with Cancer 2. Hematologic Alterations: Impaired function of blood cells • a. Abnormal wbc’s: impaired immunity • b. Diminished rbc’s and platelets: anemia and clotting disorders 3. Infections: fistula development and tumors may become necrotic; erode skin surface 4. Hemorrhage: tumor erosion, bleeding, severe anemia 5. Anorexia-Cachexia Syndrome: wasting away of client • a. Unexplained rapid weight loss, anorexia with altered smell and taste • b. Catabolic state: use of body’s tissues and muscle proteins to support cancer cell growth

  16. Nursing Care of the Client with Cancer 6. Paraneoplastic Syndromes: ectopic sites with excess hormone production • a. Parathyroid hormone (hypercalcemia) • b. Ectopic secretion of insulin (hypoglycemia) • c. Antidiuretic hormone (ADH: fluid retention) • d. Adrenocorticotropic hormone (ACTH) • Pain: major concern of clients and families associated with cancer a. Types of cancer pain • 1. Acute: symptom that led to diagnosis • 2. Chronic: may be related to treatment or to progression of disease b. Causes of pain • 1. Direct tumor involvement including metastatic pain • 2. Nerve compression • 3. Involvement of visceral organs

  17. Nursing Care of the Client with Cancer 8. Physical Stress: body tries to respond and destroy neoplasm • a. Fatigue • b. Weight loss • c. Anemia • d. Dehydration • e. Electrolyte imbalances 9. Psychological Stress • a. Cancer equals death sentence • b. Guilt from poor health habits • c. Fear of pain, suffering, death • d. Stigmatized

  18. Nursing Care of the Client with Cancer • Collaborative Care A. Diagnostic Tests: used to diagnose cancer 1. Determine location of cancer • a. Xrays • b. Computed tomography • c. Ultrasounds • d. Magnetic resonance imaging • e. Nuclear imaging • f. Angiography 2. Diagnosis of cellular type of can be done through tissue samples from biopsies, shedded cells (e.g. Papanicolaou smear) washings • a. Cytologic Examination: tissue examined under microscope • b. Identification System of Tumors: Classification – Grading -- Staging

  19. Nursing Care of the Client with Cancer 1. Classification: according to the tissue or cell of origin, e.g. sarcoma, from supportive 2. Grading: • a. Evaluates degree of differentiation and rate of growth • b. Grade 1 (least aggressive) to Grade 4 (most aggressive) 3. Staging • a. Relative tumor size and extent of disease • b. TNM (Tumor size; Nodes: lymph node involvement; Metastases)

  20. Nursing Care of the Client with Cancer 3. Tumor markers: specific proteins which indicate malignancy • a. PSA (Prostatic-specific antigen): prostate cancer • b. CEA (Carcinoembryonic antigen): colon cancer • c. Alkaline Phosphatase: bone metastasis 4 Direct Visualization • a. Sigmoidoscopy • b. Cystoscopy • c. Endoscopy • d. Bronchoscopy • e. Exploratory surgery; lymph node biopsies to determine metastases

  21. Nursing Care of the Client with Cancer Other non-specific tests • a. CBC, Differential • b. Electrolytes • c. Blood Chemistries: (liver enzymes: alanine aminotransferase (ALT); aspartate aminotransferase (AST) lactic dehydrogenase (LDH)

  22. Nursing Care of the Client with Cancer Treatment Goals: depending on type and stage of cancer A. Cure • 1. Recover from specific cancer with treatment • 2. Alert for reoccurrence • 3. May involve rehabilitation with physical and occupational therapy • 4. Three Seasons of survival • a. Diagnosis/treatment • b. Extended survival: treatment completed and watchful waiting • c. Permanent survival: risk of recurrence is small B. Control: of symptoms and progression of cancer • 1. Continued surveillance • 2. Treatment when indicated (e.g. some bladder cancer, prostate cancer) C. Palliation of symptoms: may involve terminal care if client’s cancer is not responding to treatment

  23. Nursing Care of the Client with Cancer Treatment Options (depend on type of cancer) alone or with combination A. Chemotherapy • 1. Chemotherapy • a. Includes phase-specific and non-phase specific drugs for specific cancer types • b. Often combinations of drugs in specific protocols over varying time periods • c. Cell-kill hypothesis: with each cell cycle a percentage of cancerous cells are killed but some remain; repeating chemo kills more cells until those left can be handled by body’s immune system

  24. Nursing Care of the Client with Cancer 2. Classes of Chemotherapy Drugs a. Alkylating agents • 1. Action: create defects in tumor DNA • 2. Examples: Nitrogen Mustard, Cisplatin b. Antimetabolites • 1. Action: specific for S phase • 2. Examples: Methotrexate; 5 fluorouracil • 3. Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia, leukopenia c. Antitumor Antibiotics • 1. Action: non-phase specific; interfere with DNA • 2. Examples: Actinomycin D, Bleomycin • 3. Toxic Effect: damage to cardiac muscle

  25. Nursing Care of the Client with Cancer d. Miotic inhibitors • 1. Action: Prevent cell division during M phase • 2. Examples: Vincristine, Vinblastine • 3. Toxic Effects: affects neurotransmission, alopecia, bone marrow depression e. Hormones • 1. Action: stage specific G1 • 2. Example: Corticosteroids f. Hormone Antagonist • 1. Action: block hormones on hormone-binding tumors (breast, prostate, endometrium; cause tumor regression • 2. Examples: Tamoxifen (breast); Flutamide (prostate) • 3. Toxic Effects: altered secondary sex characteristics

  26. Nursing Care of the Client with Cancer Effects of Chemotherapy • a. Tissues (fast growing) frequently affected • b. Examples: mucous membranes, hair cells, bone marrow, specific organs with specific agents, reproductive organs (all fetal toxic, impair ability to reproduce) 4. Administration of chemotherapeutic agents a. Trained and certified personnel, according to established guidelines b. Preparation • 1. Protect personnel from toxic effects • 2. Extreme care for correct dosage; double check with physician orders, pharmacist’s preparation c. Proper management clients’ excretement

  27. Nursing Care of the Client with Cancer d. Routes • 1. Oral • 2. Body cavity (intraperitoneal or intrapleural) • 3. Intravenous a. Use of vascular access devices because of threat of extravasation (leakage into tissues) and long-term therapy b. Types of vascular access devices • 1. PICC lines (peripherally inserted central catheters) • 2. Tunnelled catheters (Hickman, Groshong) • 3. Surgically implanted ports (accessed with 90o angle needle)

  28. Nursing Care of the Client with Cancer Nursing care of clients receiving chemotherapy 1. Assess and manage • a. Toxic effects of drugs (report to physician) • b. Side effects of drugs: manage nausea and vomiting, inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical interventions 2. Monitor lab results (drugs withheld if blood counts seriously low); blood and blood product administration 3. Assess for dehydration, oncologic emergencies 4. Teach regarding fatigue, immunosuppression precautions 5. Provide emotional and spiritual support to clients and families

  29. Nursing Care of the Client with Cancer B. Surgery • 1. Diagnosis, staging, and sometimes treatment of cancer • 2. Involves removal of body part, organ, sometimes with altered functioning (e.g. colostomy) • 3. Debulking (decrease size of) tumors in advanced cases • 4. Reconstruction and rehabilitation (e.g. breast implant post mastectomy) • 5. Psychological support to deal with surgery as well as cancer diagnosis

  30. Nursing Care of the Client with Cancer C. Radiation Therapy 1. Treatment of choice for some tumors to kill or reduce tumor, relieve pain or obstruction 2. Delivery • a. Teletherapy (external): radiation delivered in uniform dose to tumor • b. Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it • c. Combination 3. Goals • a. Maximum tumor control with minimal damage to normal tissues • b. Caregivers must protect selves by using shields, distancing and limiting time with client, following safety protocols

  31. Nursing Care of the Client with Cancer 4. Treatment Schedules • a. Planned according to radiosensitivity of tumor, tolerance of client • b. Monitor blood cell counts 5. Side Effects • a. Skin (external radiation): blanching, erythema, sloughing • b. Ulcerated mucous membranes: pain, lack of saliva • c. Gastrointestinal: nausea and vomiting, diarrhea, bleeding, sometimes fistula formation • d. Radiation pneumonia

  32. Penetrating capacity of different types of radiation

  33. The inverse square law of radiation exposure

  34. Nursing Care of the Client with Cancer D. Biotherapy • 1. Modification of biologic processes that result in malignancies; based on immune surveillance hypothesis • 2. Used for hematological malignancies, renal and melanoma • 3. Monoclonal antibodies (inoculate animal with tumor antigen and retrieve antibodies against tumor for human) E. Photodynamic Therapy • 1. Client giving photosensitizing compound which concentrates in malignant tissue • 2. Later given laser treatment to destroy tumor

  35. Nursing Care of the Client with Cancer F. Bone Marrow Transplantation and Peripheral Blood Stem Cell Transplantation • 1. Stimulation of nonfunctioning marrow or replace bone marrow • 2. Common treatment for leukemias G. Pain Control • 1. Includes pain directly from cancer, treatment, or unrelated • 2. Necessary for continuing function or comfort in terminally ill clients • 3. Goal is maximum relief with minimal side effects • 4. Multiple combinations of analgesics (narcotic and non-narcotic) and adjuvants such as steroids or antidepressants; includes around the clock (ATC) schedule with additional medications for break-through pain • 5. Multiple routes of medications • 6. May involve injections of anesthetics into nerve, surgical severing of nerves radiation • 7. May need to progress to stronger pain medications as pain increases and client develops tolerance to pain medication

  36. Nursing Care of the Client with Cancer • Nursing Diagnoses for Clients with Cancer A. Anxiety • 1. Therapeutic interactions with client and family; community resources such as American Cancer Society, “I Can Cope” • 2. Availability of community resources for terminally ill (Hospice care in-patient, home care) B. Disturbed Body Image • 1. Includes loss of body parts (e.g. amputations); appearance changes (skin, hair); altered functions (e.g. colostomy); cachexic appearance, loss of energy, ability to be productive • 2. Fear of rejection, stigma C. Anticipatory Grieving • 1. Facing death and making preparations for death: will be consideration • 2. Offer realistic hope that cancer treatment may be successful

  37. Nursing Care of the Client with Cancer D. Risk for Infection E. Risk for Injury • 1. Organ obstruction • 2. Pathological fractures F. Altered Nutrition: less than body requirements • 1. Consultation with dietician, lab evaluation of nutritional status • 2. Managing problems with eating: anorexia, nausea and vomiting • 3. May involve use of parenteral nutrition G. Impaired Tissue Integrity • 1. Oral, pharyngeal, esophageal tissues (due to chemotherapy, bleeding due to low platelet counts, fungal infections such as thrush) • 2. Teach inspection, frequent oral hygiene, specific non-irritating products, thrush control

  38. Nursing Care of the Client with Cancer Oncologic Emergencies A. Pericaridal Effusion and Neoplastic Cardiac Tamponade • 1. Concern: compression of heart by fluid in pericardial sac, compromised cardiac output • 2. Treatment: pericardiocentesis B. Superior Vena Cava Syndrome • 1. Concern: obstruction of venous system with increased venous pressure and stasis; facial and neck edema with slow progression to respiration distress • 2. Treatment: respiratory support; decrease tumor size with radiation or chemotherapy C. Sepsis and Septic Shock • 1. Concern: Early recognition of infection • 2. Treatment: prompt

  39. Nursing Care of the Client with Cancer D.Spinal Cord Compression • 1. Concern: pressure from expanding tumor can cause irreversible paraplegia; back pain initial symptom with progressive paresthesia and leg pain and weakness • 2. Treatment: early detection and radiation or surgical decompression E. Obstructive Uropathy • 1. Concern: blockage of urine flow; undiagnosed can result in renal failure • 2. Treatment: restore urine flow

  40. Compression of the superior vena cava in SVC syndrome

  41. Nursing Care of the Client with Cancer F. Hypercalcemia • 1. Concern: high calcium from ectopic parathyroid hormone or metastases • 2. Behaviors: fatigue, muscle weakness, polyuria, constipation progressing to coma, seizures • 3. Treatment: restore fluids with intravenous saline; loop diuretics; more definitive treatments G. Hyperuricemia • 1. Concern: occurs with rapid necrosis of tumor cells as with chemotherapy; can result in renal damage and failure • 2. Prevention and treatment with fluids and Alopurinol (Zyloprim) H. SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion) • 1. Concern: ectopic ADH production from tumor leads to excessive hyponatremia • 2. Treatment: restore sodium level

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