Oncologic Nursing

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  • 1. ONCOLOGIC NURSING Ma. Victoria J. Recinto RN, USRN University of the Philippines Manila Philippine General Hospital
  • 2. NEOPLASIA DIFFERENCES BENIGN (Tumor) MALIGNANT (CA) Differentiation Well Poor Encapsulation (+) (-) Metastasis (-) (+) Prognosis Good Poor Tx Modalities Surgery Surgery, Irradiation, Chemotx, BM transplant
  • 3. Predisposing Factors: Carcinogenesis
    • G-enetic
    • I-mmunosuppression
    • V-iral (Human Papilloma, Epstein-Barr, Hepa B)
    • E-nv’tal
      • Physical
        • Radiation, UV rays, nuclear explosion
        • Chronic irritation, direct trauma
      • Chemical
        • Acids, alkalis, hydrocarbons, dye
        • Food (  fat,  fiber) & Food additives (Nitrites)
        • Drugs (Stillbestrol, urethane)
        • Hormones
        • Smoking
  • 4. Grading of Cancer
    • Classifies the cellular aspects of CA
    • Grade I: cells differ slightly from N cells, well-differentiated (mild dysplasia)
    • Grade II: cells are more abN, mod. differentiated (mod. dysplasia)
    • Grade III: cells are very abN, poorly differentiated (severe dysplasia)
    • Grade IV: cells are immature (anaplasia), undifferentiated
  • 5. Staging of Cancer
    • Classifies the clinical aspects of CA
    • Stage O: carcinoma in situ
    • Stage I: tumor limited to the tissue of origin, localized tissue growth
    • Stage II: limited local spread
    • Stage III: extensive local & regional spread
    • Stage IV: metastatis
  • 6. WARNING/DANGER SIGNS OF CANCER
    • C-hange in bowel/bladder habits
    • A- sore that does not heal
    • U-nusual bleeding/discharge
    • T-hickening of a lump in breast or elsewhere
    • I-ndigestion/dysphagia
    • O-bvious change in a wart or mole
    • N-agging cough/hoarseness
    • U-nexplained anemia
    • S-udden wt loss
  • 7. EARLY DETECTION OF CANCER
    • Mammography
    • Pap smear
    • Stool for occult blood
    • Sigmoidoscopy, colonoscopy
    • Breast self-examination
    • Testicular self-examination
    • Skin inspection
  • 8. Breast Self-Examination (BSE)
    • Done 7-10 days after menses
    • Postmenopausal or s/p hysterectomy: specific day of the month
    • Inspection: In front of the mirror with arms at sides, arms overhead & arms at hips (WOF changes in shape, dimpling of skin or any changes in nipple)
  • 9. Breast Self-Examination (BSE)
    • Palpation: While in shower/bath or lying down with folded towel under breast being examined
    • Use the R hand to examine L breast & vice versa
    • Use the pads of 2 nd , 3 rd & 4 th fingers
    • Use small, circular motions in spiral or in an up-and-down motion to examine entire breast & under the arm (WOF lump, hard knot or thickened tissue)
  • 10. Testicular Self-Examination (TSE)
    • Same day, q month, right after a warm shower (scrotal skin is moist & relaxed)
    • Gently lift each testicle, each one should feel like an egg, firm but not hard & smooth without lumps
    • Using both hands, place middle fingers underside of each testicle & thumbs on top & gently roll the testicles (WOF lumps, swelling or mass)
  • 11. CANCER TX MODALITIES: Surgery
    • Prophylactic
      • With premalignant condition or with strong family hx of CA
    • Curative
      • Removal of all gross & microscopic tumor
    • Control (cytoreductive)
      • “ debulking” procedure,  the no. of CA cells,  the chance of other tx will be successful
  • 12. CANCER TX MODALITIES: Surgery
    • Palliative
      • Improves quality of life during survival time
      •  pain; relieve obstruction (airway, GI or GU), relieve pressure on brain & spinal cord, prevent hemorrhage, remove infected or ulcerated tumors or drain abscesses
    • Reconstructive or rehabilitative
      • Improves quality of life by restoring maximal function & appearance (breast reconstruction s/p mastectomy)
  • 13. CANCER TX MODALITIES: Chemotherapy
    • Kills CA cells & rapidly producing cells (skin, hair, BM, Reproductive tract, GIT,)
      • Antimetabolites: N2 mustard
      • Plant alkaloid: Vincristine & Vinblastine
      • Alkylating: Methotrexate
      • Hormones (DES)/ steroids
      • Antineoplastic antibiotics
  • 14. CANCER TX MODALITIES: Chemotherapy
    • Major S/E & Nursing Interventions
    • Hair: alopecia
      • Encourage pt to wear wigs, cap
      • Temporary, hair will regrow in 3-6 mos. after chemo with new color & texture
    • BM: depression
      • Anemia: CBR, O2 as ordered
      • Leukemia: reverse isolation, strict HW, asepsis
      • Thrombocytopenia: Bleeding precautions
  • 15. CANCER TX MODALITIES: Chemotherapy
    • Major S/E & Nursing Interventions
    • GIT: N/V
      • Antiemetics 4-6 hrs. pre-chemo & post chemo as ordered
      • NPO temporarily
      • Bland diet post chemo
    • Stomatitis
      • Oral care
      • Ice chips/popsicles
    • Diarrhea
      • Antidiarrheals
      • Monitor VS, I/O, WOF dehydration
    • WOF paralytic ileus (with Vincristine)
  • 16. CANCER TX MODALITIES: Chemotherapy
    • Major S/E & Nursing Interventions
    • Reproductive tract: sterility
      • Encourage sperm banking for M
    • Renal damage:  uric acid
      • Allopurinol as ordered
    • Neuro disturbance: peripheral neuropathy
      • Skin, hand & foot care (like in PVD & DM)
  • 17. Alkylating Meds
    • Cell-cycle nonspecific
    • Nitrogen Mustards
      • Chlorambucil (Leukeran) & Mechlorethamine (Mustargen): hyperuricemia
      • Cyclophosphamide (Cytoxan): taken without food, S/E: alopecia, hemorrhagic cystitis (hematuria, dysuria)
      • Ifosfamide (Ifex)
      • Melphalan (Alkeran)
      • Uracil mustard
  • 18. Alkylating Meds
    • Nitrosoureas
      • Carmustine (BiCNU)
      • Lomustine (CeeNU)
      • Streptozocin (Zanosar)
    • Alkylating-like Meds
      • Altretamine (Hexalen)
      • Busulfan (Myleran): hyperuricemia
      • Cisplatin (Platinol): ototoxicity & nephrotoxicity (given amifostine [Ethyol] prior to  risk), hypoK, hypoCa, hypoMg
      • Dacarbazine (DTIC-Dome)
      • Thiotepa (Thioplex)
  • 19. Anti-tumor Antibiotics
    • Cell-cycle nonspecific
    • Bleomycin SO4 (Blenoxane): pulmonary toxicity
    • Dactinomycin (Actinomycin D, Cosmegan)
    • Daunorubicin (Cerubidine, DaunoXome): causes CHF & dysrhythmias
    • Doxorubicin (Adriamycin) & Idarubicin (Idamycin): cardiotoxicity (given Dexraxozane [Zinecard] to prevent cardiomyopathy)
  • 20. Anti-tumor Antibiotics
    • Mitomycin (Mutamycin)
    • Mitoxantrone (Novantrone)
    • Pentostatin (Nipent)
    • Plicamycin (Mithracin): affects bleeding time
    • Valrubicin (Valstar)
  • 21. Antimetabolites
    • Cell-cycle phase-specific (S phase)
    • Capecitabine (Xeloda)
    • Cladribine (Leustatin)
    • Cytarabine (ara-C, Cytosar-U): alopecia, stomatitis, hyperuricemia, hepatotoxicity
    • Floxuridine (FUDR)
    • Fludarabine (Fludara)
  • 22. Antimetabolites
    • Methotrexate (Folex) & 5-Fluorouracil (Adrucil): alopecia, stomatitis, hyperuricemia, photosensitivity, hepatotoxicity, hema, GI & skin toxicity
      • Leucovorin rescue (given leucovorin [folinic acid or citrovorum factor) to prevent toxicity r/t Methotrexate
    • Hydroxyurea (Hydrea)
    • 6-Mercaptopurine (Purinethol): hyperuricemia, hepatotoxicity
    • Procarbazine (Matulane)
    • Thioguanide
  • 23. Mitotic Inhibitors (Vinca Alkaloids)
    • Cell-cycle phase-specific: M phase
    • Docetaxel (Taxotere)
    • Etoposide (VePesid)
    • Teniposide (Vumon)
    • Vinblastine SO4 (Velban)
    • Vincristine SO4 (Oncovin): neurotoxicity (numbness & tingling of fingers & toes), peripheral neuropathy, ptosis
    • Vinorelbine (Navelbine)
  • 24. Immunomodulator Agents
    • Stimulate immune system to recognize CA cells & destroy them (Interleukins)
    • Slow down tumor cell division, causes CA cells to differentiate into non-proliferative forms (Interferons)
  • 25. Immunomodulator Agents
    • Aldesleukin (Proleukin, Interleukin-2)
    • Interferon alfa-2a
    • Interferon alfa-2b
    • Interferon alfa-n3 (Alferon N) Levamisole (Ergamisole)
    • Recombinant interferon-  (Intron A, Roferon A)
    • Rituximab (Rituxan)
  • 26. Colony-Stimulating Factors
    • Induce rapid BM recovery after chemotherapy
    • Granulocyte-Macrophage: Sargramostim (Leukin, Prokine)
    • Granulocyte: Filgrastim (Neupogen)
    • Erythropoetin: Epoetin alfa (Epogen)
  • 27. CANCER TX MODALITIES: Radiation
    • Use of ionizing radiation that kills CA & rapidly growing cells & inhibit their growth
    • Types of energy
      • Alpha rays: don’t penetrate skin tissue
      • Beta rays: penetrate skin (e.g. internal radiation)
      • Gamma rays: penetrate deeper, underlying tissues (e.g. external radiation)
  • 28. CANCER TX MODALITIES: Radiation
    • Factors Affecting Delivery
      • Half-life: time required for the ½ of the radioisotope to decay
      • Time: less time, less exposure
      • Distance: the farther the source, the lesser the exposure
      • Shielding: Alpha & Beta rays can be blocked by gloves, Gamma rays can be blocked by thick, lead gown & concrete
  • 29. CANCER TX MODALITIES: Radiation
    • Methods of Delivery
      • Internal: utilizes injection/ implantation of radioactive isotopes proximal to CA sites for specified period of time
        • Sealed: within a container, don’t contaminate with body fluids
        • Unsealed: e.g. Phosphorus 32
      • External: uses electromagnetic waves e.g. Cobalt
  • 30. CANCER TX MODALITIES: Teletherapy/Beam Radiation
    • Source: external radiation
    • Pt does not emit radiation & does not pose a hazard to anyone else
    • Wash area with water & mild soap, using the hand than a washcloth, rinse & pat dry with soft towel
    • Don’t remove radiation markings from the skin
  • 31. CANCER TX MODALITIES: Teletherapy/Beam Radiation
    • No powder, ointment, lotion or cream on area unless ordered
    • Wear soft clothing over the area, avoid constrictive garments
    • Avoid sun & heat exposure
    • WOF weeping of skin (moist desquamation) & if noted, cleanse the area with warm water & pat dry, apply antibiotic or steroid cream as ordered & expose the site to air
  • 32. CANCER TX MODALITIES: Brachytherapy Radiation
    • Source: internal radiation (sealed or unsealed)
    • For a pd. of time the pt emits radiation & pose a hazard to others
  • 33. CANCER TX MODALITIES: Brachytherapy Radiation
    • Unsealed Radiation Source
      • Administered PO or IV or instillation into body cavities
      • It enters body fluids, eliminated via various excreta (radioactive & harmful to others esp. the 1 st 48 hrs)
  • 34. CANCER TX MODALITIES: Brachytherapy Radiation
    • Sealed Radiation Source
      • Temporary or permanent solid implant within tumor target tissues
      • The pt emits radiation while the implant is in place, but the excreta is not radioactive
      • Place the pt in a private room with private bath
      • Place a caution sign on the pt’s door
  • 35. CANCER TX MODALITIES: Brachytherapy Radiation
    • Sealed Radiation Source
      • Organize nursing tasks to minimize exposure to radiation source
      • Nursing staff assignments should be rotated, a nurse should never care for more than 1 pt with radiation implant at a time, avoid assigning a pregnant nurse
      • Limit time to 30 mins per care provider/shift
  • 36. CANCER TX MODALITIES: Brachytherapy Radiation
    • Sealed Radiation Source
      • Wear a dosimeter film badge to measure radiation exposure
      • Wear a lead shield
      • Do not allow children <16 y/o or pregnant woman to visit the pt
      • Limit visitors to 30 min./day, at least 6 ft from the pt
      • Save bed linens & dressings until the source is removed then dispose
      • Other equipments can be removed from the room at any time
  • 37. CANCER TX MODALITIES: Brachytherapy Radiation
    • Dislodged Sealed Radiation Source
      • Don’t touch it with bare hands, use a long-handled forceps to place the source in a lead container kept in the pt’s room & notify MD
      • If unable to locate the radiation source, bar visitors & notify MD
  • 38. CANCER TX MODALITIES: Brachytherapy Radiation
    • Sealed Radiation Source Removal
      • Pt is no longer radioactive
      • Inform the pt that sexual partner cannot “catch” CA
      • Pt may resume sexual intercourse after 7-10 days for cervical or vaginal implant
      • Perform povidone-iodine douche as ordered for cervical implant
      • Administer Fleet enema as ordered
      • Notify MD if N/V/D, frequent urination, vaginal or rectal bleeding, hematuria, foul-smelling vaginal discharge, abdominal pain/distention or fever occurs
  • 39. CANCER TX MODALITIES: Radiation
    • Major S/E & Nursing Interventions
      • Skin erythema, redness, irritation & sloughing of tissue
        • Assist in bathing the pt
        • Force fluids
        • Avoid lotion, talcum powder; may use cornstarch or olive oil
      • BM depression (same as in chemo)
      • GIT disturbance: Dysgeusia-  taste sensation esp. with internal implant
        • Oral care, avoid hot & cold foods
  • 40. LEUKEMIA
    • Group of malignant disease
    • Rapid  immature WBC, competes nutrition with mature WBC and production of RBC and platelets
    • N= 500 RBC: 1 WBC
  • 41. LEUKEMIA
  • 42. CLASSIFICATION OF LEUKEMIA
    • Lympho- affects lymphocytes
    • Myelo- affects myeloblasts
    • Acute/Blastic- affects immature cells
    • Chronic/Cystic- affects mature cells
    • Most common in children: Acute Lymphocytic Leukemia (ALL), peak onset 2-6 y/o, M>F
    • Acute Myelogenous Leukemia (AML): peak onset 15-39 y/o
  • 43. Signs and Symptoms: LEUKEMIA
    • From invasion of BM (“Nadir”)
      • Infection:  T, poor wound healing, sore throat, bone weakens  fracture, bone & joint pains, lymphadenopathy
      • Bleeding: hemorrhage, petechiae, epistaxis, hematoma, hematuria, hematemesis, hepatosplenomegaly
      • Anemia: pallor, fatigue, anorexia, constipation
  • 44. Signs and Symptoms: LEUKEMIA
    • From invasion of CNS
      •  ICP:  LOC, severe HA, vomiting, papilledema, seizures
      • CN VII or spinal nerve involvement
    • From invasion of kidneys, testes, prostate, ovaries, GI and lungs
  • 45. LEUKEMIA
    • Diagnostic Tests
      • PBS- (+) immature WBC
      • CBC-  immature WBC,  RBC,  platelets
        • Done weekly during maintenance phase of chemotherapy
      • Lumbar Puncture- CNS affectation
        • Shrimp/fetal/C-position, avoid neck flexion may occlude airway of infants and children
  • 46. LEUKEMIA
    • Diagnostic Tests
      • Bone Marrow Aspiration- (+) blast cells (immature WBC), common site: iliac crest
        • Post op: apply direct pressure, lie on affected side to stop bleeding
      • Bone Scan- to determine bone involvement (fractures)
      • CT Scan: to determine organ involvement
  • 47. LEUKEMIA
    • Triad Management
      • Surgery (most preferred)
      • (Cranial) Irradiation
      • Chemotherapy
    • BM transplant
  • 48. Nursing Management: LEUKEMIA
      • Assess for common side effects: anorexia, nausea and vomiting (give antiemetics 30mins prior to chemo and continue until 1 day post chemo), WOF dehydration
  • 49. Nursing Management: LEUKEMIA
      • Assure pt that alopecia and hirsutism are temporary side effects, hair will regrow in 3-6 mos. With new color & texture
  • 50. Nursing Management: LEUKEMIA
      • Assess for stomatitis (oral ulcers)
        • Oral care: alcohol-free mouthwash, pNSS with or without NaHCO3
        • Use soft-bristled toothbrush, cotton plegets
        • Apply Xylocaine (topical anesthetic) on mouth before meals
        • Diet: soft and bland according to child’s preference, small frequent feedings
  • 51. Nursing Management: LEUKEMIA
      • Protect pt from infection
        • Strict hand washing
        • Reverse isolation
      • Protect pt from additional fatigue
        • Bed rest
        • Activities balanced with rest
  • 52. Nursing Management: LEUKEMIA
      • Protect pt from bleeding
        • Minimize parenteral injections
        • Apply pressure on venipuncture sites
        • Use electric razor in shaving
  • 53. Nursing Management: LEUKEMIA
      • Encourage verbalization of feelings & concerns
      • Introduce the family to other families of children with CA
      • Consult social services & chaplains as necessary
  • 54. HODGKIN’S DISEASE/LYMPHOMA
    • Involves lymph nodes, tonsils, spleen & BM
    • (+) Reed-Sternberg cell in the nodes
    • S/Sx
    •  T, A/, malaise, fatigue & weakness, wt loss
    • Anemia, thrombocytopenia
    • Enlarged lymph nodes, spleen & liver
    • (+) bx of cervical lymph nodes (affected 1 st )
    • (+) CT scan of liver & spleen
  • 55. HODGKIN’S DISEASE/LYMPHOMA
    • Management
    • External radiation (tx of choice)
    • Multiagent chemotx (if extensive)
    • WOF S/E: infection, bleeding
    • Sperm banking (possibility of sterility for M)
  • 56. MULTIPLE MYELOMA
    • Malignant proliferation of plasma cells and tumors within the bone, destroying the bone & invading the lymph nodes, spleen & liver
    • abN plasma cells produce an abN Ab (myeloma protein or Bence Jones protein) found in blood & urine
    •  production of Ig & Ab,  uric acid & Ca  RF
  • 57. S/Sx: MULTIPLE MYELOMA
    • Bone pain (pelvis, spine, ribs)
    • Osteoporesis (bone loss, pathological fractures)
    • Spinal cord compression & paraplegia
    • Weakness & fatigue
    • Recurrent infections
    • Anemia
    • Bence Jones proteinuria,  total serum protein, Ca & uric acid levels
    • RF
    • Thrombocytopenia, granulocytopenia
  • 58. Nursing Interventions: MULTIPLE MYELOMA
    • Administer as ordered
      • Chemotherapy
      • IVF & diuretics (to eliminate Ca)
      • BT for anemia
      • Analgesics, antibiotics
    • WOF bleeding, infection, fractures, RF
    • Force fluids
    • Encourage ambulation
    • Provide skeletal support during moving, turning & ambulating
    • Maintain hazard-free env’t
  • 59. TESTICULAR CANCER
    • Occurs between ages 15-40
    • Common sites of mets: lymph nodes, bone, lungs, adrenal glands & liver
    • Types
      • Germinal tumors (Seminomas, Nonseminomas)
      • Nongerminal tumors (Interstitial cell tumors, Androblastoma)
  • 60. S/Sx: TESTICULAR CANCER
    • Painless testicular swelling
    • Dragging sensation in the scrotum
    • S/Sx of mets: palpable lymphadenopathy, abdominal masses, gynecomastia
    • Late S/Sx: back or bone pain & respiratory Sx
  • 61. Tx: TESTICULAR CANCER
    • Chemotherapy
    • Radiation
    • Surgery
      • Unilateral orchiectomy- for dx & primary surgical mgt.
      • Radical retroperitoneal lymph node dissection- to stage the CA &  tumor vol.
    • Reproductive options: sperm storage, donor insemination & adoption
  • 62. Nursing Interventions: s/p Testicular Surgery
    • Suture removal: 7-10 days post-op
    • May resume N activities within 1 week except for lifting heavy objects > 20 lbs or stair climbing
    • Perform monthly testicular self-exam on the remaining testicle
  • 63. BREAST CANCER
    • Common sites of mets: lymph nodes, bone, lungs, brain & liver
    • Precipitating factors
      • Genetics
      • Early menarche & late menopause
      • Nulliparity
      • Obesity
      • High-dose radiation exposure to chest
  • 64. S/Sx: BREAST CANCER
    • Mass felt during BSE (usually in the upper outer quadrant or beneath the nipple)
    • Fixed, irregular, nonencapsulated mass
    • Painless (early stage) or painful (late stage) mass
    • Nipple retraction or elevation
    • Assymetrical breast (affected breast higher)
    • Bloody or clear nipple d/c
  • 65. S/Sx: BREAST CANCER
    • Skin dimpling, retraction or ulceration
    • Skin edema or peau d’orange skin
    • Axillary lymphadenopathy
    • Lymphedema of affected arm
    • Presence of lesion on mammography
    • S/Sx of lung/bone mets
  • 66. Nonsurgical Tx: BREAST CANCER
    • Chemotx
    • Radiation tx
    • Hormonal manipulation in post menopausal women
    • Meds: Tamoxifen (Nolvadex) for estrogen receptor-positive tumors
  • 67. Surgical Tx: BREAST CANCER
    • Lumpectomy: removal of tumor with lymph node dissection
    • Simple Mastectomy: removal of breast tissue & nipple, lymph nodes left intact
    • Modified Radical Mastectomy: removal of breast tissue, nipple & lymph nodes, muscles left intact
    • Halsted Radical Mastectomy: removal of breast tissue, nipple, lymph nodes & underlying muscles
  • 68. Surgical Tx: BREAST CANCER
    • Oophorectomy: for estrogen receptor-positive tumors
    • Ablative therapy with adrenalectomy or chemical ablation which blocks cortisol, androstenedione & aldosterone production
  • 69. Nursing Interventions: s/p Breast Surgery
    • Semi-Fowlers’ position, turn from back to unaffected side, with affected arm elevated above the heart level to promote drainage & prevent lymphedema
    • Use a pressure sleeve if edema is severe
    • Maintain Jackson-Pratt suction, record the amount & characteristic of draiange
    • No IV, injections, BP, venipunctures in affected arm
    • Low Na-diet, diuretics for severe lymphedema
    • Refer to MD & PT for appropriate exercise program
  • 70. Health Teaching: s/p Breast Surgery
    • Protect & avoid overuse of the hand & arm during the 1 st few months
    • Keep the affected arm elevated to prevent lymphedema
    • Incision care with lanolin to soften & prevent wound contractures
    • BSE on the remaining breast
    • Avoid strong sunlight or heat to the affected arm
    • Don’t carry anything heavy over the affected arm
  • 71. Health Teaching: s/p Breast Surgery
    • Avoid constrictive clothing/jewelry, trauma, cuts, bruises or burns to the affected arm
    • Wear gloves when gardening, washing dishes/clothes
    • Use thick oven mitten mitts when cooking
    • Use a thimble when sewing
    • Apply lanolin hand cream several times daily
    • Use cream cuticle remover
    • Notify MD if S/ of inflammation occur in the affected arm
    • Wear a Medic-Alert bracelet stating lymphedema arm
  • 72. CERVICAL CANCER
    • Premalignant changes: (Stage I) mild dysplasia to (Stage II) mod. dysplasia to (Stage III) severe dysplasia to carcinoma in situ
    • Common sites of mets: pelvis & lymphatics
    • Precipitating factors
      • Low socioeconomic groups
      • Early 1 st marriage
      • Early & frequent intercourse
      • Multiple sex partners
      • High parity
      • Poor hygiene
  • 73. S/Sx: CERVICAL CANCER
    • Painless vaginal bleeding postmenstrually & postcoitally
    • Foul-smelling or serosanguinous vaginal d/c
    • Leakage of urine or feces from the vagina
    • Dysuria, hematuria
    • Pelvic, lower back, leg or groin pain
    • A/, wt loss
    • Changes on Pap smear
  • 74. Tx: CERVICAL CANCER
    • Nonsurgical
      • Chemotherapy
      • Cryosurgery
      • External radiation
      • Internal radiation (intracavitary)
      • Laser therapy
    • Surgical
      • Conization
      • Hysterectomy
      • Pelvic exenteration
  • 75. CERVICAL CA: Laser Therapy
    • Energy from the beam is absorbed by fluid in the tissues, causing them to vaporize
    • Minimal bleeding & slight vaginal d/c is expected after the procedure, healing occurs in 6-12 wks
  • 76. CERVICAL CA: Cryosurgery
    • Involves freezing of the tissues by a probe with subsequent necrosis
    • No anesthesia required
    • Cramping may occur during the procedure
    • A heavy, watery d/c is expected several wks after the procedure, use tampons
    • Avoid sexual intercourse
  • 77. CERVICAL CA: Conization
    • A cone-shaped area of the cervix is removed
    • For women who want further child bearing
    • Long-term follow-up is needed (new lesions may develop)
    • Cx: hemorrhage, uterine perforation, incompetent cervix, cervical stenosis & preterm labor
  • 78. CERVICAL CA: Hysterectomy
    • Vaginal approach for microinvasive CA if childbearing is not desired
    • Radical hysterectomy & bilateral lymph node dissection for CA that spread beyond the cervix but not to the pelvic wall
  • 79. Nursing Interventions: s/p Hysterectomy
    • Monitor vaginal bleeding (>1 saturated pad/hr)
    • Avoid stair climbing for 1 mo.
    • Avoid tub baths & sitting for long periods
    • Avoid strenous activity or lifting >20 lbs
    • Avoid sexual intercourse for 3-6 wks
  • 80. CERVICAL CA: Pelvic exenteration
    • Radical surgical procedure for recurrent CA
    • When the bladder is removed, an ileal conduit is created & located at the R side of the abdomen to divert urine
    • A colostomy is created on the L side of the abdomen for the passage of feces
  • 81. CERVICAL CA: Types of Pelvic Exenteration
    • Anterior
      • Removal of uterus, ovaries, fallopian tubes, vagina, bladder, urethra & pelvic lymph nodes
    • Posterior
      • Removal of uterus, ovaries, fallopian tubes, descending colon, rectum & anal cnal
    • Total
      • Combo of anterior & posterior
  • 82. Nursing Interventions: s/p Pelvic exenteration
    • Administer perineal irrigation with half-strength H2O2 & NS
    • Avoid strenous activity for 6 mos.
    • Perineal opening may drain for several mos.
    • Ileal conduit & colostomy care
    • Sexual counseling: vaginal intercourse is not possible s/p anterior & total pelvic exenteration
  • 83. OVARIAN CANCER
    • Grows rapidly, spreads fast, often bilateral
    • Common sites of mets: pelvis, lymphatics & peritoneum
    • Usually detected late: Poor prognosis
    • Exploratory laparotomy: to dx & stage the tumor
  • 84. S/Sx: OVARIAN CANCER
    • Abdominal discomfort or swelling
    • GI disturbance
    • Dysfunctional vaginal bleeding
    • Abdominal mass
  • 85. Tx: OVARIAN CANCER
    • External radiation: if with mets
    • Chemotherapy: done post-op for all stages of CA
    • Intraperitoneal chemotx: instillation into abdominal cavity
    • Immunotherapy: promotes tumor resistance
    • Surgery: TAHBSO
  • 86. ENDOMETRIAL CANCER
    • Slow-growing tumor asso. with menopausal years
    • Common sites of mets: ovaries, pelvis, peritoneum, lymphatics & via blood to the lungs, liver & bone
    • Precipitating Factors
      • Hx of uterine polyps
      • Nulliparity
      • Polycystic ovary disease
      • Estrogen stimulation
      • Late menopause
      • Family hx
  • 87. S/Sx: ENDOMETRIAL CANCER
    • Postmenopausal bleeding
    • Watery, serosanguinous discharge
    • Low back, pelvic or abdominal pain
    • Enlarged uterus in advanced stages
  • 88. Tx: ENDOMETRIAL CANCER
    • External or internal radiation
    • Chemotherapy for advanced or recurrent CA
    • Medroxyprogesterone (Depo-Provera) or Megestrol) Megace for estrogen-dependent tumors
    • Tamoxifen (Nolvadex): antiestrogen
    • Surgery: TAHBSO
  • 89. GASTRIC CANCER
    • Predisposing Factors
      • Diet: high in complex CHO, grains & salt, low in fresh green, leafy vegetables & fruits
      • Use of nitrates
      • Smoking, alcoholism
      • Hx of gastric ulcers
    • Cx: hemorrhage, obstruction, mets & dumping syndrome
    • Goal of Tx: remove the tumor & provide nutritional support
  • 90. S/Sx: GASTRIC CANCER
    • A/N/V, wt loss
    • Fatigue, anemia
    • Indigestion, epigastric discomfort
    • A sensation of pressure in the stomach
    • Dysphagia
    • Ascites
    • Palpable mass
  • 91. Tx: GASTRIC CANCER
    • Chemotx
    • Radiation
    • Surgery
      • Subtotal gastrectomy
        • Bilroth I: Gastroduodenostomy
        • Bilroth II: Gastrojejunostomy
      • Total gastrectomy
        • Esophagojejunostomy
  • 92. Nursing Interventions: GASTRIC CANCER
    • Fowler’s position for comfort: Pain meds as ordered
    • Monitor Hgb, Hct: BT as ordered
    • NPO for 1-3 days post-op until peristalsis returns
    • Monitor I/O: IVF & e+ as ordered
    • Monitor NGT suction, don’t irrigate or remove NGT
  • 93. Nursing Interventions: GASTRIC CANCER
    • Progressive diet to 6 small bland meals/day
    • Monitor wt, nutritional status: Small, bland, easy digestible meals with vit & mineral supplements
    • WOF Cx: hemorrhage, dumping syndrome, diarrhea, hypoglycemia, Vit B12 deficiency
  • 94. PANCREATIC CANCER
    • More common in blacks than in whites, in smokers & in men
    • Linked with DM, alcohol use, hx of pancreatitis, high fat diet, env’tal chemicals
    • With poor prognosis
  • 95. S/Sx: PANCREATIC CANCER
    • N/V
    • Jaundice
    • Unexplained wt. loss
    • Clay-colored stool
    • Glucose intolerance
    • Abdominal pain
  • 96. Tx: PANCREATIC CANCER
    • Radiation
    • Chemotherapy
    • Whipple’s procedure: pancreaticoduodenectomy with removal of distal third of the stomach, pancreaticojejunostomy, gastrojejunostomy & choledochojejunostomy
  • 97. INTESTINAL TUMORS
    • Develop in the cells lining the bowel wall or develop as polyps in the colon or rectum
    • Cx: bowel perforation with peritonitis, abscess & fistula formation, hemorrhage & complete gut obstruction
    • Common sites of mets: via lymphatics & blood, colon & other organs
  • 98. S/Sx: INTESTINAL TUMORS
    • A/V, malaise, wt loss
    • Blood in stools, anemia
    • AbN stools
      • Ascending colon tumor: diarrhea
      • Descending colon tumor: constipation with some diarrhea, ribbon-like stool
      • Rectal tumor: alternating constipation & diarrhea
    • Guarding or abdominal distention
    • Abdominal mass & cachexia (late signs)
  • 99. Nursing Interventions: INTESTINAL TUMORS
    • WOF bowel perforation:  BP,  HR,  T, weak pulse, distended abdomen
    • WOF intestinal obstruction: (EARLY S/Sx-  peristalsis,  to  bowel sounds) fecal vomiting, pain, constipation, distended abdomen
    • Radiation pre-op
    • Chemotherapy post-op
    • Surgery: bowel resection & creation of colo or ileostomy
  • 100. COLO/ILEOSTOMY PRE-OP CARE
    • Consult with enterostomal therapist to identify optimal placement of ostomy
    • Low-residue diet for 1-2 days pre-op
    • Give intestinal antiseptics & antibiotics, laxatives & enemas as ordered
  • 101. COLOSTOMY POST-OP CARE
    • Apply petroleum jelly over the stoma to keep it moist followed by dry sterile gauze if pouch system is not yet in place
    • Monitor the stoma for size, unusual bleeding or necrotic tissue
    • Monitor the stoma for color
      • N: pink or red indicating  vascularity
      • Pale: anemia, Violet/Blue/Black: compromised circulation
  • 102. COLOSTOMY POST-OP CARE
    • Check pouch system for proper fit & leakage
    • Ascending colon colostomy: expect liquid stool
    • Transverse colon colostomy: expect loose to semiformed stool
    • Descending colon: expect close to N stool
    • Empty pouch when 1/3 full, remove feces from the skin
    • Avoid gas/odor-forming foods
  • 103. COLOSTOMY POST-OP CARE
    • WOF perineal wound infection (if present)
    • Administer as ordered
      • Analgesics & antibiotics
      • Stoma irrigation
  • 104. ILEOSTOMY POST-OP CARE
    • Post-op drainage: dark green to yellow (as the pt begins to eat)
    • Expect liquid stool
    • WOF dehydration & e+ imbalance
    • Avoid suppositories through ileostomy
  • 105. LUNG CANCER
    • Lungs: common target for mets from other organs
    • Bronchiogenic carcinoma: direct extension & via lymphatics
    • 4 Major Types
      • Small (Oat) Cell
      • Epidermal (Squamous Cell)
      • Adenocarcinoma
      • Large cell anaplastic carcinoma
  • 106. LUNG CANCER
    • Causes
      • Cigarette smoking
      • Env’tal & occupational pollutants
    • Dx: CXR (lesion or mass), bronchoscopy & sputum cytological studies
  • 107. S/Sx: LUNG CANCER
    • Cough
    • Dyspnea
    • Hoarseness
    • Hemoptysis
    • Chest pain
    • A/ wt loss
    • Weakness
  • 108. Nursing Interventions: LUNG CANCER
    • Monitor VS, pulse oximetry
    • Fowler’s position
    • WOF RR distress, tracheal deviation, bleeding, infection & e+ imbalance
    • Activity as tolerated, rest periods, active/passive ROM
    • Diet:  calorie, high CHON,  Vit
    • Administer as ordered
      • O2, bronchodilators, steroids
      • Analgesics
      • CPT
  • 109. Tx: LUNG CANCER
    • Radiation
    • Chemotherapy
    • Immunotherapy
    • Surgery
      • Laser therapy: to relieve endobronchial obstruction
      • Thoracentesis & pleurodesis: to remove pleural fluid & relieve hypoxia
      • Thoracotomy with pneumonectomy or lobectomy or segmental resection
  • 110. Pre-op Care: LUNG CANCER
    • Explain the potential post-op need for chest tubes
    • Closed chest drainage is not used for pneumonectomy & the serum fluid that accumulates in the empty thoracic cavity will consolidate, preventing mediastinal shift
  • 111. Post-op Care: LUNG CANCER
    • Monitor VS, breath sounds
    • Maintain chest tube drainage system, WOF SQ emphysema
    • Avoid complete lateral turning
    • Activity as tolerated, active ROM of the operative shoulder
    • Administer O2 as ordered
  • 112. PROSTATE CANCER
    • Slow-growing, androgen type of adenocarcinoma in M >50 y/o
    • Common sites of mets: bloodstream, lymphatics, pelvis, spine, bone
  • 113. S/Sx: PROSTATE CANCER
    • (-) in early stages
    • Hard, pea-sized nodule on rectal exam
    • Hematuria
    • Late S/Sx: wt loss, urinary obstruction, pain radiating from the lumbosacral area down the leg
    • Prostate-specific Ag test: monitors the pt’s response to tx
    •  serum acid phosphatase: indicates spread & mets
  • 114. Tx: PROSTATE CANCER
    • Hormonal manipulation
      • LT: leuprolide acetate (Lupron), flutamide (Eulexin) or DES
      • Goserelin acetate (Zoladex) when orchiectomy or estrogen administration is not acceptable for the pt
    • Radiation & Chemotx for hormone-resistant tumors
  • 115. Tx: PROSTATE CANCER
    • Palliative surgery: Orchiectomy (to  testosterone production)
    • Cryosurgical ablation (liquid nitrogen freezes the prostate, dead cells are absorbed by the body)
    • Transurethral resection of the prostate (TURP) or prostatectomy
  • 116. PROSTATE CA: TURP
    • Insertion of a scope into the urethra to excise prostatic tissue
    • Bleeding is common post-op, WOF hemorrhage
    • Continuous bladder irrigation (CBI) post-op to maintain the urine at a pink color
    • Bladder spasms are common post-op, give antispasmodics as ordered
    • WOF dribbling & incontinence
    • Sterility may or may not occur post-op
  • 117. PROSTATE CA: Prostatectomy Point of comparison Suprapubic Retropubic Perineal Technique Via abdominal & bladder incision Via low abdominal incision without opening the bladder Via incision bet. scrotum & anus Hemorrhage Yes No No Bladder spasms Yes Yes but less Urinary incontinence common
  • 118. PROSTATE CA: Prostatectomy Point of comparison Suprapubic Retropubic Perineal CBI Yes Yes - Sterility Yes Yes Yes Remarks Abdominal dressing soaked frequently with urine, Longer healing time than TURP Minimal abdominal drainage WOF infection, (No rectal tubes, rectal temp. taking & enema) Teach perineal exercises
  • 119. Nursing Interventions: s/p TURP
    • Monitor VS, U.O., hematuria & clots, Hgb & Hct levels
    • Force fluids
    • Expect red to light pink urine for 24 hrs, turning to amber in 3 days (then encourage ambulation)
    • WOF arterial bleeding (bright red urine with clots):  CBI & notify MD
    • WOF venous bleeding (burgundy-colored urine): notify MD who will apply traction on the catheter
    • Continuous urge to void is N but not encouraged to prevent bladder spasms
    • Antibiotics, analgesics, stool softeners & antispasmodics as ordered
  • 120. Nursing Interventions: s/p TURP
    • Monitor 3-way foley catheter (for the balloon (30-45 cc), inflow & outflow)
    • Use pNSS only to prevent water intoxication or hypoNa (  LOC,  HR,  BP)
    • Maintain infusion rate as ordered, if (+) clots:  rate
    • For obstructed catheter: turn off CBI, irrigate with 30-50 ml pNSS, notify MD if it does not resolve
    • CBI is d/c usually after 1-2 days, WOF continence & urinary retention
  • 121. Discharge Health Teaching: s/p TURP
    • Avoid heavy lifting, stressful exercise, driving, Valsalva maneuver & sexual intercourse for 2-6 wks
    • Drink 2.4-3L fluids/day before 8 pm
    • Avoid alcohol, caffeine & spicy foods to prevent overstimulation of the bladder
    • Pt may pass small clots & tissue debris for several days
    • If urine becomes less in amount & bloody, rest & force fluids, notify MD if persistent
  • 122. Nursing Interventions: s/p Suprapubic Prostatectomy
    • Monitor foley catheter & suprapubic catheter drainage
    • As ordered, clamp the suprapubic cath after foley cath is removed (2-4 days post-op) & instruct the pt to void, measure residual urine by unclamping the cath & measuring the U.O.
    • Prepare for removal of suprapubic cath if pt consistently empties bladder & residual urine is <75 ml