Timby/Smith: Introductory Medical-Surgical Nursing, 11/e

1. Timby/Smith: Introductory Medical-Surgical Nursing, 11/e Chapter 18: Caring for Clients With Cancer

2. Cancer • Pathophysiology: abnormal, unrelated cell proliferation; neoplasms—new growths of abnormal tissue • Classifications • Tissue type: based on origin • Carcinomas: epithelial cells • Lymphomas: organs that fight infection • Leukemias: organs that form blood • Sarcomas: connective tissue; bones or muscles • Growth: benign or malignant

3. Cancer—(cont.) • Benign tumors • Noninvasive • Grow large • Slow growth rate • Do not usually cause death unless impairs function of vital organ • Malignant tumors • Invasive • Uncontrolled growth • Causes alterations in cell membrane; fluid movement in and out of cell • Tumor-specific antigens

4. Cancer—(cont.) • Metastasis: development of secondary tumor from the primary tumor; lymph nodes and blood vessels • Carcinogenesis: malignant transformation • Steps • Initial process: alters the genetic structure of the cell DNA; carcinogens • Promotion: cells begin to mutate cell populations • Progression: invades adjacent tissues and metastasizes

5. Cancer—(cont.) • Etiology • Incidence of cancer • Second leading cause of death in United States • One-half men and one-third women • Most common cancer: lung cancer • Men: prostate, lung, and colon cancer • Women: breast, lung, and colon cancer • Damage to DNA: mutated or damaged; oncogenes and tumor suppressor genes

6. Cancer—(cont.) • Contributing factors • Chemical agents: effects of tobacco and nicotine, exposure to asbestos, pesticides, formaldehydes • Lungs, liver, and kidneys: due to biotransformation • Environmental: exposure to sunlight, radiation, pollutants, electromagnetic fields, nuclear power plants • Diet: foods high in fat or nitrates, alcohol, obesity • Viruses and bacteria; Kaposi’s sarcoma, Helicobacter pylori

7. Cancer—(cont.) • Contributing factors—(cont.) • Medications: immunosuppressive drugs, hormone replacements, anticancer drugs • Immune system: defective • Fails to recognize malignant cells or not stimulated to fight cancer cells • Malignant cells survive and proliferate

8. Question A client has all of the following in his health history. Which would contribute most to the development of oral cancer? A) Alcohol abuse B) Poor dental hygiene C) Frequent bouts of tonsillitis D) Chewing smokeless tobacco

9. Answer D) Chewing smokeless tobacco Rationale: Smokeless tobacco or snuff is a precipitating factor for oral cancer.

10. Cancer—(cont.) • Signs and Symptoms • American Cancer Society (2012) • CAUTION • Other: headaches, weight loss, chronic pain, persistent fatigue, low-grade fever, infections C- Change in bowel/bladder habits A- An unhealing sore U- Unusual bleeding T- Thickening lump I- Indigestion O- Obvious change in size of wart or mole N- Nagging cough

11. Cancer—(cont.) • Cancer Prevention • Education: awareness of warning signs and factors of cancer development • Cancer screening programs • Periodic physical examinations • Emphasize and teach self-examinations; breasts, skin, testicles • Avoid risk factors

12. Cancer—(cont.) • Diagnostic Methods • Client’s history, physical examination • Laboratory tests • Tumor markers: proteins, antigens, hormones, genes, or enzymes released by cancer cells • Complete blood count: CBC; anemia • X-ray imaging: contrast medium; iodine or barium • Computed tomography (CT) scan: tumor density, size, volume, or location

13. Cancer—(cont.) • Diagnostic Methods—(cont.) • Magnetic resonance imaging (MRI) • Nuclear imaging: radioimmunoconjugates, PET, SPECT; “hot spots” and “cold spots” • Ultrasound: solid and cystic tumors of abdomen, chest, breast, pelvis, and heart • Fluoroscopy: movement of body structures; Example: barium study/swallow • Biopsy, frozen sections, cytology • Endoscopy: gastroscopy, bronchoscopy, colonoscopy

14. Question A nurse is conducting a skin assessment on a client. Which of the following characteristics of a mole on the skin warrants further evaluation by a physician? A) Brown color B) Irregular shape C) Located on the neck D) Skin around area sunburned

15. Answer B) Irregular shape Rationale: Nevi (moles) are typically brown. An irregularity shaped mole warrants further evaluation, particularly if the mole was once circular and has changed.

16. Cancer—(cont.) • American Joint Committee on Cancer; TNM classification; tumor size, node involvement, metastasis • Stages • 0—cancer is in situ; malignant cells confined • I, II, and III—spread to lymph nodes and/or organs • IV—metastasized to other organs • Grading: differentiated (closely resemble tissue of origin) and undifferentiated (little resemblance of tissue to origin); graded from I to IV

17. Cancer—(cont.) • Treatment • Surgery: primary method of diagnosing, staging, and treating • Tumor excision: local and wide (radical), debulking or cytoreductive surgery • Salvage surgery: local recurrence of cancer • Example: lumpectomy, mastectomy • Prophylactic/preventative surgery: family history or genetic predisposition

18. Cancer—(cont.) • Surgery—(cont.) • Palliative: helps relieve uncomfortable symptoms • Examples: paracentesis, thoracentesis, nerve blocks • Reconstructive/plastic surgery: correct defects • Mohs surgery: shaving off layers of skin; chemosurgery—topical chemical application to skin • Other: cryosurgery, electrosurgery, laser

19. Cancer—(cont.) • Treatment—(cont.) • Radiation: destroys cell by breaking a strand of DNA molecule, preventing growing, and dividing • Types • External radiation therapy (ERT): target tumors and lymph nodes • Internal radiation therapy (brachytherapy): interstitial implants, intracavitary implants • Systemic internal radiation therapy: iodine-131; administered orally, IV, or body cavity

20. Cancer—(cont.) • Radiation side effects: alopecia, erythema, desquamation, stomatitis, xerostomia, anorexia, nausea, cystitis, pneumonitis, fatigue • Other • Myelosuppression: depression of bone marrow • Leukopenia: decreased white blood cell count • Thrombocytopenia: decreased platelet count • Fibrosis: small intestine, lungs, bladder; cataracts, sterility, new cancers

21. Cancer—(cont.) • Radiation Safety • Length of exposure • Private rooms • Distance • Shielding: lead-lined • Contaminated articles; gloves

22. Question A client has frequent nausea and vomiting following radiation to the abdomen. An appropriate intervention for the nurse to use is: A) Administer antibiotics before meals. B) Monitor fluid intake and output. C) Serve the diet while food is hot. D) Provide music and conversation during meals.

23. Answer B) Monitor fluid intake and output. Rationale: Fluid imbalance could easily result from nausea and vomiting; therefore, it is important to monitor fluid intake and output.

24. Cancer—(cont.) • Treatment—(cont.) • Chemotherapy: antineoplastic agents—interfering with cellular function • Cell-cycle patterns: synthesis, mitosis, gaps 1 and 2, gap 0, checkpoints and cyclins • Drugs: interfering with RNA and DNA synthesis • Examples: alkylating agents, nitrosoureas, topoisomerase I, antimetabolites • Routes: IV routes (PICC, Hickman, IVAD), oral, IM, SQ, topical, intrathecal, intraperitoneal

25. Cancer—(cont.) • Chemotherapy side effects: nausea, vomiting, stomatitis, alopecia, myelosuppression, fatigue • Nursing Management • Monitor for gout, increased uric acid levels, joint pain, edema • Dietary modifications: small, frequent meals • Increase fluid intake: 2500 to 3000 mL/day • Report excessive weight loss, change in level of consciousness, paresthesia

26. Cancer—(cont.) • Peripheral Stem Cell Transplant • Replaces bone marrow destroyed by cancer or cancer treatments; engraftment • Types • Autologous: frozen and reinfused from self • Allogeneic: donor stem cells; GVHD, immunosuppressant drugs; minitransplant • Syngeneic: identical twin with identical tissue type; does not cause GVHD

27. Cancer—(cont.) • Targeted Therapies • Biologic response modifiers (BRMs) • Nonspecific biologic response modifiers (BCGs) • Examples: cytokines—interferons, interleukin-2 • Monoclonal antibody immunotherapy (MOABs) • Cancer vaccines—clinical trials • Hyperthermia—thermal therapy • Photodynamic therapy (PDT) • Gene therapy

28. Nursing Care Plan: Cancer • Nursing Diagnosis: Fatigue • Encourage protein and calorie intake. • Plan care around energy level. • Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements • Encourage intake of sufficient calories. • Administer antiemetics as ordered before meals. • Nursing Diagnosis: Disturbed Body Image • Explore strengths and resources.

29. Cancer—(cont.) Care of the Terminally Ill Client • Gently carry out tasks to reduce pain/discomfort. • Control pain. • Provide adequate fluid/nutrition. • Keep patient warm and dry. • Control odors. • Maintain dignity.