Nursing Care of A patient with Cancer.ppt

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

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

 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

 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

 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

 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

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

 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)

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

 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

 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

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

 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

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

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)
7. 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

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

 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

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)

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

Other non-specific tests
a. CBC, Differential
b. Electrolytes
c. Blood Chemistries: (liver enzymes:
alanine aminotransferase (ALT); aspartate
aminotransferase (AST) lactic
dehydrogenase (LDH)

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

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

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

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

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

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)

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

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

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

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

Penetrating capacity of different types of radiation

The inverse square law of radiation exposure

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

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

 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

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

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

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

Compression of the superior vena cava in SVC
syndrome

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

Nursing Care of A patient with Cancer.ppt

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