Chapter 25

1. Chapter 25 The Patient with Cancer

2. 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)

3. 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

4. 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

5. 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

6. 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

7. Prevention and Early Detection Health promotion Avoidance of carcinogens Identification of high-risk people Screening for cancer

8. 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

9. 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

10. Radiotherapy Radiotherapy: given internally or externally 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 External radiation Internal radiation Side effects

11. Figure 25-3

12. 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

13. 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

14. 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

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

16. 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

17. Assessment: Health History Chief complaint Functional assessment Review of systems Physical Examination

18. 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

19. 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

20. Nursing Diagnoses Anxiety Ineffective Denial: Deficient Knowledge:

21. 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

22. 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

23. Risk for Injury Pneumonitis and pulmonary fibrosis Cardiac toxicity Neurotoxicity Thrombocytopenia Anemia Reproductive cells

24. 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

25. Imbalanced Nutrition: Less Than Body Requirements High-protein, high-calorie diet Small, frequent feedings Light exercise before meals may stimulate the appetite Nutritional supplements (such as Carnation Instant Breakfast, Ensure, or Sustacal), enteral feedings, or both may be ordered if the patient has excessive weight loss Be familiar with the specific antineoplastic agents so that the patient can be advised of any specific food restrictions Various combinations of antiemetics and sedatives can be tried as ordered to obtain relief from nausea

26. Impaired Oral Mucous Membranes Frequent, gentle mouth care Artificial saliva Encourage increased fluid intake, chew sugarless gum or candies, suck on ice chips, and moisten dry food before eating Eat soft foods, and avoid foods that are acidic, salty, or spicy Use soft-bristled or foam toothbrush

27. Constipation Monitor patient’s bowel movements The physician may prescribe a high-fiber diet, stool softeners, laxatives, and phosphate or bisphosphate enemas to prevent or treat constipation

28. Fatigue Assess the patient’s need for assistance and schedule activities to conserve energy Encourage patient to prioritize activities and ask others to assume less important ones Daily naps and mild exercise helpful

29. Disturbed Body Image Be sensitive to patient’s concern about hair loss Use wigs, scarves, or hats The American Cancer Society lends wigs to patients free of charge The society also sponsors the “Look Good-Feel Better” program to help patients look their best during therapy

30. Dysfunctional Grieving Listen in an accepting way that lets the patient know the feelings are understood Support patient and provide practical information about adapting to the loss Participation in a support group may help the patient learn new coping strategies and begin to resolve the grief process

31. Impaired Family Processes Encourage family to remain involved Family members may need help to handle their responses to the patient’s illness Obtain a social work consultation if necessary to assist them with insurance and disability claims and financial assistance referrals

32. Ineffective Therapeutic Regimen Management Pretreatment teaching plan informs patient of what the prescribed therapy involves Chemotherapy Teaching plan includes drugs administered, potential side effects, related precautions Provide written information to supplement the verbal teaching Explore what patient has heard about chemotherapy; correct any misconceptions

33. Recovery and Rehabilitation If the outcome of treatment appears to be a cure, the patient and family are usually overjoyed Some patients become excessively concerned with their bodies, constantly looking for new evidence of cancer Periodic checkups essential but may be dreaded because the patient realizes that complete or permanent recovery cannot be guaranteed If signs of possible recurrence, patients are concerned As patients recover from the effects of cancer and cancer therapy, rehabilitation may be needed to restore them to the highest possible level of functioning

34. Terminal Illness Although increasing numbers of people are surviving cancer, it is still the second leading cause of death If treatment is unsuccessful, patient begins to decline For patients who wish to die at home, hospice provides support and teaching Focus: keep patient’s symptoms, especially pain, under control during the final period of the illness Provides bereavement care after the patient’s death

35. Oncologic Emergencies Conditions sometimes develop that require emergency intervention as a result of the disease process or therapy Examples: hypercalcemia, syndrome of inappropriate antidiuretic hormone, disseminated intravascular coagulation, and spinal cord compression