Chapter 25

1. Chapter 25 The Patient with Cancer

2. Learning Objectives • Explain the differences between benign and malignant tumors. • List the most common sites of cancer in men and women. • Describe measures to reduce the risk of cancer. • Define terms used to name and classify cancer. • List nursing responsibilities in the care of patients having diagnostic tests to detect possible cancer. • Explain the nursing care of patients undergoing each type of cancer therapy: surgery, radiation, chemotherapy, and biotherapy. • Assist in developing a nursing care plan for the terminally ill patient with cancer and the patient’s family.

3. What Is Cancer?

4. Normal Body Cells A normal cell has the following characteristics Distinct, recognizable appearance typical of all cells from a particular tissue (“tissue of origin”); has a single small nucleus The ability to perform a specific function when mature The production of substances that hold cells from the same type of tissue closely together Ability to recognize other cells and identify their tissue of origin Reproduce in a controlled manner to produce additional identical cells only as needed for growth and replacement Cell division inhibited by inadequate space or insufficient nutrients Remain in their tissue of origin (except for blood cells, which migrate)

5. Benign Tumors Relatively harmless, primarily because they do not spread to other parts of the body Problems, however, if they create pressure on or obstruct body organs Surgical removal of benign tumors often recommended

6. Malignant Tumors Characteristics of cancer cells are Change in appearance from normal cells Inability to properly perform function of tissue of origin; may assume functions of other cells Not readily recognized by other cells Abnormal proteins (tumor markers) on cell surface Random, disorganized, uncontrolled growth pattern Continue dividing even when no need for additional cells, inadequate space, or inadequate nutrients Ability to migrate from one tissue or organ to another

7. Malignant Tumors Can invade nearby tissues or disperse cells to colonize distant parts of the body Regional invasion The movement of cancer cells into adjoining tissue Metastasis Process by which cancer spreads to distant sites Most common sites of metastasis: liver, brain, bone, lungs Once metastasis has occurred, cancer treatment is more difficult and less likely to be curative

8. Malignant Transformation Factors that promote the transformation of normal cells to malignant cells are increasing age, diet, hormones, and chronic irritation Carcinogens Substances that damage cell DNA, causing normal cells to become malignant

9. Classification of Tumors Anatomic site Type of tissue from which they developed Staging system for cancer TNM system T refers to the tumor N to regional lymph nodes M to distant metastases

10. Risk Factors Genetic and environmental Changes in genetic information of a normal cell can cause alterations that lead to malignancies Carcinogens Cigarette smoke, asbestos, and nitrites Drugs Diethylstilbestrol, androgenic steroids, and high-dose unopposed synthetic estrogens Familial cancers Appear at a higher rate than expected in one family Hereditary cancers Predictable patterns of inheritance based on a single gene

11. Seven Warning Signs The American Cancer Society has identified seven warning signs associated with many common types of cancer Guide the nurse and the public in identifying signs and symptoms that require medical evaluation The first letters of the warning signs spell out CAUTION, making it easier to remember them

12. Prevention and Early Detection Health promotion Diet low in fat, calories, and preservatives, and high in fiber with at least five servings of various fruits and vegetables daily Appropriate calorie intake to maintain or attain normal body weight important because obesity is a risk factor for some cancers A balanced program of activity and rest with stress management may enable the body to resist diseases, including cancer

13. Prevention and Early Detection Avoidance of carcinogens Cigarette smoke Alcohol Intercourse with multiple partners A variety of chemicals and drugs Excessive sun exposure Identification of high-risk people High-risk people can be monitored closely to detect cancer early Screening for cancer The value of early detection and treatment The seven warning signs of cancer How to do self-examinations (breast, skin, testicular) The importance of periodic examinations for common cancers

14. Diagnosis of Cancer Health history Physical examination Diagnostic procedures When cancer is suspected, when high-risk people are screened, or when determining the extent of known disease Tissue examinations, imaging studies, endoscopic procedures, and laboratory tests

15. Medical Treatment of Cancer

16. Surgery To diagnose and stage the cancer, relieve symptoms, maintain function, effect a cure, or reconstruct affected structures May be extensive or simple Treatment based on type of cancer, location, staging, and extent of metastasis Surgeon often consults with a radiologist and an oncologist to determine the best therapy

17. Radiotherapy Ionizing radiation used in treatment of disease Treat cancer because malignant cells are more sensitive than are normal cells to radiation Immediate and delayed effects on cells Immediate: cell death due to damage to cell membrane The delayed effect is alteration of DNA, which impairs the cell’s ability to reproduce Radiotherapy: given internally or externally

18. Radiotherapy Caregiver safety The amount of radiation received by those who come in contact with the patient depends on the time of exposure, distance from radiation source, and amount of shielding between the caregiver and the source Unless direct care is being given, remain at least 6 feet away from the source Effective shielding depends on type of rays emitted The denser the material composing the shield, the better protection it provides

19. Figure 25-3

20. Radiotherapy External radiation Procedure Special x-ray machine delivers radiation to area Patient preparation Patient goes through a treatment simulation; includes CT scanning, to determine the exact location to be treated Radiation therapist marks the skin over area to be treated Instruct patient not to remove the markings until given permission by physician

21. Radiotherapy Internal radiation Introduction of radiation source into the body Patients emit radiation and do pose a threat to others until the source is removed or excreted Sealed-source radiation Radiation inserted into body in a sealed container Unsealed-source radiation

22. Radiotherapy Side effects Bone marrow suppression Alopecia Anorexia Dry mouth Effects on reproduction

23. Chemotherapy Chemical agents to treat disease Antineoplastic Destroy rapidly dividing cells; may be used alone or in combination with other forms of treatment Types of antineoplastic drugs Cytotoxic agents Hormones and hormone antagonists Biologic response modifiers Radioimmunotherapy Administered by physician or nurse who has had specialized education Route: oral, intramuscular, intravenous, intracavity, intrathecal

24. Chemotherapy Side effects Bone marrow suppression Nausea and vomiting Alopecia Extravasation

25. Biotherapy Hematopoietic growth factors Colony-stimulating factors: stimulate the bone marrow to produce platelets, red, and white blood cells Biologic response modifiers (BRMs) Intended to boost the body’s existing defenses Act directly on malignant cells or stimulate the immune system to act against them Monoclonal antibodies Specific for proteins on surface of certain cancer cells

26. Bone Marrow and Stem Cell Transplantation Bone marrow transplantation: used after treatment of leukemia and lymphoma with chemotherapy and/or radiation that destroys bone marrow Stem cell transplantation: treats the destruction of the bone marrow caused by the chemotherapy and radiotherapy Transplantation of bone marrow or peripheral blood stem cells: restores the blood manufacturing cells

27. Hormone Therapy Various treatments to suppress natural hormone secretion, block hormone actions, or provide supplemental hormones

28. Complementary and Alternative Therapies Nontraditional treatments Relaxation techniques, guided imagery, music, meditation, herbal remedies, and acupuncture Complementary therapy Nontraditional therapy used with conventional treatment Alternative therapy The patient uses nontraditional therapy in place of traditional treatment

29. Unproven Methods of Cancer Treatment American Cancer Society discourages treatments that have not been studied Alternative therapies can be harmful and may delay treatment with potentially effective conventional therapies See Box 25-2, p. 383

30. Nursing Care: Diagnostic Phase

31. Assessment: Health History Chief complaint Pain, lesions, lumps, or changes in body function Complete description of problem and signs and symptoms Past medical history Document chronic illnesses, serious injuries, surgeries, and hospitalizations Family history Inquire about the incidence of cancer and other serious diseases in the patient’s immediate family

32. Assessment: Health History Review of systems Record any of the following signs and symptoms: pain, lumps, fatigue, activity intolerance, lesions of the skin or mucous membranes, easy bruising or bleeding, headache, vision or hearing disturbances, hoarseness, cough, dyspnea, hemoptysis, loss of appetite, difficulty swallowing, digestive disturbances, blood in the urine or stool, and change in bowel pattern

33. Assessment: Health History Functional assessment Describe the patient’s diet, use of alcohol and tobacco, safe sex practices, activity, sleep routines Document the occupation and describe a usual day Assess health practices, including frequency of breast self-examination, testicular examination, and medical checkups Identify concerns about living conditions and/or location Note sources of stress; support and coping strategies

34. Assessment: Physical Examination Vital signs, height, and weight Inspect face, scalp, and oral mucosa for lesions Palpate the neck for enlarged lymph nodes Inspect skin for color, lesions, edema, and bruising Auscultate breath sounds and observe respiratory effort Inspect breasts for symmetry, dimpling, and abnormal skin color, and palpate for lumps or thickened areas Inspect abdomen for distention, auscultate for bowel sounds, and palpate for masses Inspect genitalia for lesions Palpate scrotum for descended testicles/testicular lumps

35. Interventions

36. Ineffective Denial Deny the seriousness of the situation and do not seek medical care Encourage people to learn the warning signs of cancer and to report them promptly

37. Anxiety Patient needs encouragement, support, and honest information Remain hopeful but don’t give false reassurance May show this stress through anger, irritability, fear, or depression When coping is not effective, refer to a psychiatric clinical nurse specialist or a mental health counselor

38. Deficient Knowledge Tell patient about diagnostic procedures, including preparation, what the procedure is like, and any specific postprocedure care

39. Nursing Care: Treatment Phase

40. Assessment: Health History Note patient’s diagnosis and treatment plan Complete drug profile; record allergies prominently Review the systems to detect significant symptoms related to cancer or treatment: fatigue, weakness, headache, sore or dry mouth, dyspnea, palpitations, altered taste sensations, nausea, diarrhea, constipation, blood in stools, change in urinary frequency, hematuria or dysuria, sexual dysfunction, numbness, and tingling sensations

41. Assessment: Health History Determine the effects of the illness and therapy on the patient’s daily functioning Explore patient’s knowledge, fears, concerns, and coping strategies

42. Assessment: Physical Examination Note general appearance, level of consciousness, posture, and gait Assess mental and emotional state Measure weight and vital signs and compare with previous measurements Assess skin for lesions/bruises; scalp for hair loss Inspect the oral mucous membranes for lesions and inflammation

43. Assessment: Physical Examination Observe patient’s respiratory effort and auscultate the lungs Inspect the abdomen for distention, and auscultate bowel sounds Inspect and palpate the extremities for color, edema, and peripheral pulses Test extremity reflexes and sensation

44. Interventions

45. Anxiety Encourage patient to express feelings and identify the source of the anxiety Listening and touch can be very effective in reducing anxiety Recognize need for patient teaching or referrals

46. Ineffective Coping Strategies to promote coping include teaching, encouraging self-care within the patient’s limitations, treating physical signs and symptoms, emphasizing abilities, coaching in relaxation strategies, and encouraging the use of coping strategies that have been effective in the past

47. Risk for Injury Pneumonitis and pulmonary fibrosis Encourage coughing and deep breathing exercises Protect patient from exposure to people who have upper respiratory infections Cardiac toxicity Monitor for dyspnea, increasing pulse pressure, edema Neurotoxicity Protect extremities that lack normal sensation

48. Risk for Injury Thrombocytopenia Avoid trauma and bruising Minimal invasive procedures: rectal temperatures After venipunctures or injections, apply pressure for 5 minutes to control oozing Instruct patient to use soft toothbrush and an electric razor to prevent trauma to the oral tissues or the skin Assess for signs and symptoms of internal bleeding: increased pulse and respirations, restlessness, pallor, decreased urine output, and falling blood pressure

49. Risk for Injury Anemia Monitor hemoglobin and hematocrit Encourage a diet high in iron Patient should report palpitations, pallor, and excessive fatigue to the physician Reproductive cells Women are usually advised not to become pregnant within 2 years of chemotherapy or while receiving radiotherapy

50. Risk for Infection Avoid crowds and close contact with others who have infectious diseases Promptly report any signs of infection Compromised host precautions Private room Strict hand washing by all who enter the room Fresh flowers, fruits, and vegetables not allowed