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Cancer Lecture

Published in: Health & Medicine, Technology
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  1. 1. Oncology Nursing Ma. Tosca Cybil A. Torres, RN
  2. 2. Objectives <ul><li>Identify significant objective/subjective data from the client’s history using the American Cancer Society of Warning Signs (CAUTION US) </li></ul><ul><li>Formulate appropriate nursing diagnosis as to priority </li></ul><ul><li>Utilize appropriate nursing interventions to restore and maintain health with cellular functioning </li></ul><ul><li>Demonstrate core competencies in the delivery of nursing care to the client with neoplasm </li></ul><ul><li>Provide spiritual care </li></ul><ul><li>Evaluate outcome of nursing care </li></ul><ul><li>Display caring behavior </li></ul><ul><li>Integrate Christian values </li></ul>
  3. 3. Review of anatomy <ul><li>Normal cell division </li></ul>
  4. 4. Cancer <ul><li>(medical term: malignant neoplasm ) </li></ul><ul><li>is a class of diseases in which a group of cells display uncontrolled growth (division beyond the normal limits), invasion (intrusion on and destruction of adjacent tissues), and sometimes metastasis (spread to other locations in the body via lymph or blood). </li></ul><ul><li>These three malignant properties of cancers differentiate them from benign tumors , which are self-limited, do not invade or metastasize. </li></ul><ul><li>Most cancers form a tumor but some, like leukemia, do not. </li></ul><ul><li>The branch of medicine concerned with the study, diagnosis, treatment, and prevention of cancer is oncology . </li></ul>
  5. 5. Pathophysiology <ul><li>Cancer is, ultimately, a disease of genes. In order for cells to start dividing uncontrollably, genes which regulate cell growth must be damaged. </li></ul><ul><li>Proto-oncogenes are genes which promote cell growth and mitosis, and tumor suppressor genes discourage cell growth, or temporarily halt cell division to carry out DNA repair. Typically, a series of several mutations to these genes are required before a normal cell transforms into a cancer cell. </li></ul><ul><li>When normal cells are damaged beyond repair, they are eliminated by apoptosis (A). Cancer cells avoid apoptosis and continue to multiply in an unregulated manner (B). </li></ul>
  6. 6. <ul><li>Differences in Cell Growth </li></ul><ul><li>Most normal cells are limited to approximately 50-60 generations or divisions before they die. This programmed death is called senescence , and its mechanism is controlled by the cell’s normal “biological clock”. This biological clock is called “telomere”. </li></ul><ul><li>The function of the telomere is to protect the chromosomal ends of the DNA from damage. With each cell replication, the telomere is copied completely. With age, the telomere grows progressively shorter. When it shrinks below a certain level, a signal is sent to enter in to senescence. If the cell continues to divide, it will die. In contrast, cells obtained from cancer tissue do not exhibit this limitation of division and considered to be immortal. </li></ul>
  7. 7. Carcinogenesis <ul><li>☺ Is the process during which normal genes are damaged so that cells lose normal control mechanisms of growth and proliferate out of control. When the genes of a single cell are altered by a carcinogenic event, the offspring of the single cell continue to mutate and divide, producing even more virulent mutant clones. </li></ul>
  8. 8. <ul><li>Phases of carcinogenesis </li></ul><ul><li>Initiation – is the conversion of normal cell to tumor cell. It has an initiator, which is an agent that permanently and irreversibly alters DNA structure within a cell. This can occur after a single exposure to an agent, such as chemical compounds, radiation and viruses. These are examples that can initiate carcinogenesis. </li></ul><ul><li>Promotion – is the process of altering the genetic expression of a cell, by increasing DNA synthesis, increasing the number of copies of a particular gene and altering intercellular communication. A promote is an agent that favors this activity. The effects of promoting agents are transitory and potentially reversible. It is the repeated, frequent application of or exposure to a promoter that is necessary to stimulate latent tumor cells to form tumors and complete the neoplastic transformation. Examples of promoters are hormonal preparations, alcohol, tobacco, dietary fat and certain lifestyles. </li></ul><ul><li>Progression – is an irreversible phase in which the cells are led to morphologic changes and malignant behavior. Both initiation and promotion are necessary for the complete transformation of the cell. A cell must be transformed by an initiating agent before further neoplastic changes can occur. Then the promoting agent further leads the cells towards progression up to the point when malignancy occurs. </li></ul>
  9. 10. Benign Growths vs. Malignant Tumors <ul><li>Benign Growths </li></ul><ul><li>Encapsulated </li></ul><ul><li>Non-invasive </li></ul><ul><li>Limited growth </li></ul><ul><li>Doesn't metastasize </li></ul><ul><li>Rarely lethal </li></ul><ul><li>Malignant Tumors </li></ul><ul><li>Not-encapsulated </li></ul><ul><li>Invasive </li></ul><ul><li>Uncontrolled growth </li></ul><ul><li>May metastasize </li></ul><ul><li>Often lethal </li></ul>
  10. 11. Metastasis <ul><li>Cancer cells move from their original location to other sites. </li></ul><ul><ul><li>Routes of Metastasis </li></ul></ul><ul><ul><li>Local Seeding : Distribution of shed cancer cells occurs in the local area of the primary tumor. </li></ul></ul><ul><ul><li>Blood-borne Metastasis : Tumor cells enter the blood, which is the most common cause of cancer spread. </li></ul></ul><ul><ul><li>Lymphatic Spread : Primary sites rich in lymphatics are more susceptible to early metastatic spread. </li></ul></ul>
  11. 12. Metastasis <ul><li>Cells in an invasive tumour can separate off, digest a pathway through the extracellular matrix and enter the bloodstream. When they reach a permissible site, they can exit (extravasation) the blood stream and set up shop as secondary tumours (metastases). </li></ul>
  12. 13. Common Sites of Metastasis for Different Cancer Types <ul><li>Breast Cancer – bone, lung, liver, brain </li></ul><ul><li>Lung Cancer – brain, bone, liver, lymph nodes, adjacent structures </li></ul><ul><li>Colorectal Cancer – liver, lymph nodes, adjacent structures </li></ul><ul><li>Prostate Cancer – Bone(esp. spine and legs), pelvic nodes </li></ul><ul><li>Melanoma – GIT, lymph nodes, lung, brain </li></ul><ul><li>Primary Brain Cancer – CNS </li></ul>
  13. 14. Cancer Classification <ul><li>1.Solid Tumors : Associated with the organs from which they developed, such as breast or lung cancer </li></ul><ul><li>2.Hematological Cancers : Originate from blood-cell forming tissues, such as the leukemias and the lymphomas </li></ul>
  14. 15. Grading and Staging <ul><li>- Are methods used to describe the tumor, these methods describe the extent of the tumor, the extent to which malignancy has increased in size, the involvement of regional nodes, and metastatic development. </li></ul><ul><li>Grading a tumor classifies the cellular aspects of the cancer. </li></ul><ul><li>Staging classifies the clinical aspects of the cancer. </li></ul>
  15. 16. Purpose of Staging <ul><li>Aid the clinician in the planning of treatment for each patient </li></ul><ul><li>Assist in the evaluation of treatment modalities </li></ul><ul><li>Facilitate exchange of information between treatment centers </li></ul><ul><li>Evaluate the outcomes of treatment </li></ul><ul><li>Estimate the prognosis of outcomes by stage and treatment </li></ul>
  16. 17. <ul><li>GRADING </li></ul><ul><li>Grade X : Grade cannot be determined </li></ul><ul><li>Grade I : Cells differ slightly from normal cells and are well differentiated (Mild Dysplasia) </li></ul><ul><li>Grade II : Cells are abnormal and are moderately differentiated ( Moderate Dysplasia) </li></ul><ul><li>Grade III : Cells are very abnormal and are poorly differentiated ( Severe Dysplasia) </li></ul><ul><li>Grade IV : Cells are immature (anaplasia) and undifferentiated, cell of origin is difficult to determine. </li></ul>
  17. 18. STAGING <ul><li>Stage 0 : Carcinoma in Situ&quot;cancer in place&quot; </li></ul><ul><li>Stage I : Tumor limited to the tissue of origin; localized tumor growth </li></ul><ul><li>Stage II : Limited local spread </li></ul><ul><li>Stage III : Extensive local and regional spread </li></ul><ul><li>Stage IV : Metastasis </li></ul>
  18. 19. Epidemiology and risk factor assessment in oncology <ul><li>Epidemiology – is the study of the distribution and determinants of disease frequently in a certain locality or in a specific country. </li></ul><ul><li>Cancer Incidence – refers to the number of new cases of cancer. It is often expressed as incidence rate, that is, </li></ul><ul><li>The number of new cases of cancer in the population </li></ul><ul><li>The number of people in the population for a given period of time </li></ul><ul><li>Cancer mortality – refers to the number of deaths due to cancer. Cancer mortality rates reflect the overall risk of dying of cancer in a population. In the Philippines, cancer was the fourth leading cause of mortality in 1996, with a rate of 43.4. </li></ul>
  19. 20. Factors that Influence Cancer Development <ul><li>Environmental Factors </li></ul><ul><li>a. Chemical Carcinogens : Factors include chemicals, drugs, and tobacco </li></ul><ul><li>b. Physical Carcinogen : Include Ionizing Radiation (x-rays) and ultraviolet radiation. </li></ul><ul><li>c. Viral Carcinogen : Viruses capable of causing cancer are known as Oncoviruses (Epstein Barr virus, hepatitis B virus, human papilloma virus) </li></ul><ul><li>2. Dietary Factors : Include high fat and low fiber , high animal intake, preservatives, contaminants, and additives and nitrates. </li></ul><ul><li>3. Genetic Predisposition : Inherited predisposition to specific cancers </li></ul>
  20. 21. <ul><li>4. Age : Advancing age is a significant risk factor for development of cancer. </li></ul><ul><li>5. Immune Function : Incidences of cancer are higher in immunosuppressed individuals, organ transplant recipients who are taking immunosuppressive medication, and individuals with acquired immunodefficiency syndrome. </li></ul>
  21. 22. <ul><li>☺ Cancer is caused by exogenous and endogenous factors. Exogenous factors include environmental and lifestyle factors. </li></ul><ul><li>Environmental Factors Associated with Cancer: </li></ul><ul><li>Tobacco – is the most important and most known cause of cancer of the lung not only in the Philippines but all over the world. </li></ul><ul><li>☺ Active tobacco use has been linked with many cancer types: lung, oropharyngeal, bladder, pancreatic cervix and kidneys. </li></ul><ul><li>☺ Several studies have found that a clear linear relationship exist between the number of cigarettes smoked, the length of time smoking has been established as a social habit, and the risk of lung and oropharyngeal cancers. </li></ul><ul><li>☺ Side stream smoking or passive smoking is also harmful to nonsmokers because the inhale the cigarette smoke. </li></ul>Cancer risk factors
  22. 23. <ul><ul><li>Nutrition and Diet: ☺ Intake of fatty, creamy foods with red meat, as well as spicy and very saucy meals have been associated with cancer of the colon. On the other hand, intake of fiber, such as that derived from leafy vegetables, prevents cancer of the colon. ☺ Intake of fruits and vegetables that are rich in carotenoid elements, such as beta-carotene, Vitamin A, Vitamin E and selenium as well as anti-oxidants have been very beneficial especially in protecting individuals from cancer. ☺ These three-fruits, vegetables and fibers have been known as chemoprevention or chemoprophylaxis. They contain elements that prevent the formation of carcinogens by decreasing the formation rate of carcinogenic nitrosamines or phenolic diazonium compounds. They also inhibit the formation of reactive electrophiles or radicals from procarcinogens. Because they increase detoxification of procarcinigens, they prevent the development clinical neoplasia from transformed cells. </li></ul></ul>
  23. 24. <ul><ul><li>Alcohol – has been linked to cancers of the oral cavity, pharynx, larynx, esophagus and liver. Studies suggest that alcohol appears to act synergistically with smoking. So if an individual loves to drink and to smoke, cancer is likely to develop. </li></ul></ul><ul><ul><li>Sexual Behavior: d.1. Having multiple sexual partners has been found to add to the likelihood of having cervical dysplasia due to the exposure to human papilloma virus, which is implicated in cervical cancer. d.2. the number of breast cancer cases among married and celibate women has increased over the years. </li></ul></ul>
  24. 25. <ul><ul><li>Radiation: ☺ The 20th and 21st centuries have exposed most children to the rays of television. ☺ Radiation by direct sunlight over prolonged periods of time is harmful to the skin. </li></ul></ul><ul><ul><li>Drugs – drug interaction and excessive use of drugs is one probable risk factor for cancer. </li></ul></ul><ul><ul><li>☺ Diethylstilbestrol, a synthetic estrogen used in the past for the treatment of the threatened abortion, has been associated with vaginal and cervical cancers. </li></ul></ul><ul><ul><li>☺ An increase in the incidence of liver cancer among young women has been associated with oral contraceptives. Long-term use of estrogen also been linked to breast cancer. </li></ul></ul>
  25. 26. <ul><ul><li>Lifestyle related factors: ☺ Psychological trauma, emotional hurts, deep frustrations, sleepless nights and excessive burn out conditions have in one way or another contributed to cancer. ☺ Trauma in any part of the body, if not well-monitored and treated, may also lead to the development of cancer because of the proliferation on the traumatized body parts. </li></ul></ul><ul><li>Genetic predisposition </li></ul>
  26. 27. Risk factors for a specific type of cancer <ul><li>Breast cancer </li></ul><ul><ul><li>family history (immediate female relatives) </li></ul></ul><ul><ul><li>high-fat diet </li></ul></ul><ul><ul><li>obesity after menopause </li></ul></ul><ul><ul><li>early menarche, late menopause </li></ul></ul><ul><ul><li>alcohol consumption </li></ul></ul><ul><ul><li>postmenopausal estrogen and progestin </li></ul></ul><ul><ul><li>first child after age 30 </li></ul></ul><ul><li>Cervical cancer </li></ul><ul><ul><li>multiple sexual partner </li></ul></ul><ul><ul><li>having sex at early age </li></ul></ul><ul><ul><li>exposure to human papilloma virus </li></ul></ul><ul><ul><li>smoking </li></ul></ul>
  27. 28. <ul><li>Colorectal cancer </li></ul><ul><ul><li>family history (immediate relatives) </li></ul></ul><ul><ul><li>low fiber diet </li></ul></ul><ul><ul><li>history of rectal polyps </li></ul></ul><ul><li>Esophageal Cancer </li></ul><ul><ul><li>heavy alcohol consumption </li></ul></ul><ul><ul><li>smoking </li></ul></ul><ul><li>Lung Cancer </li></ul><ul><ul><li>cigarette smoking </li></ul></ul><ul><ul><li>asbestos, arsenic, and radon exposure </li></ul></ul><ul><ul><li>secondhand smoke </li></ul></ul><ul><ul><li>TB </li></ul></ul>
  28. 29. <ul><li>Skin Cancer </li></ul><ul><ul><li>excessive exposure to UV radiation (sun) </li></ul></ul><ul><ul><li>fair complexion </li></ul></ul><ul><ul><li>work with coal, tar, pitch or creosote </li></ul></ul><ul><ul><li>multiple or atypical nevi (males) </li></ul></ul><ul><li>Stomach Cancer </li></ul><ul><ul><li>family history </li></ul></ul><ul><ul><li>diet heavy in smoked, pickled or salted foods </li></ul></ul><ul><li>Testicular Cancer </li></ul><ul><ul><li>undescended testicles </li></ul></ul><ul><ul><li>consumption of hormones by mothers during pregnancy </li></ul></ul><ul><li>Prostate Cancer </li></ul><ul><ul><li>increasing of age </li></ul></ul><ul><ul><li>family history </li></ul></ul><ul><ul><li>diet high in animal fat </li></ul></ul>
  29. 30. Cancer Prevention, Screening and detection <ul><li>☺ Prevention is a priority in oncology nursing because at least one third of all cancers are preventable. </li></ul><ul><li>☺ Cancer is also curable if detected and treated early. </li></ul><ul><li>☺ The principal role of an oncology nurse as a provider of information and education in the prevention and early detection of cancer requires a basic understanding of the etiology and epidemiology of the disease. </li></ul><ul><li>☺ the most successful approach to caner control is the prevention of cancer. </li></ul>
  30. 31. Three Levels of Prevention <ul><li>Primary Prevention – at this level, the risk of cancer is reduced by avoidance of known causative agents, such as cigarettes and unhealthy foods. It also includes removal of target organs like rectal polyps and breasts cysts. Primary prevention involves paying attention to signs in the body as soon as they are noticed or felt. </li></ul><ul><li>Secondary Prevention – at this level, the natural course of the disease is favorably altered by early detection and effective prompt treatment, as in detection of tiny breast mass through regular mammography or SBE or detection of an early alteration in the bowel movement pattern for cancer of the colon or unusual monthly bleeding for uterine or ovarian cancers. </li></ul><ul><li>Tertiary Prevention – at this level, the morbidity of cancer is reduced by prompt and effective anti-tumor treatment, symptom control and rehabilitation, such as surgery for stage 1 or stage 2 breast cancer. </li></ul>
  31. 32. Prevention and Detection Measures 1. Promoting cancer awareness <ul><li>Warning Signs of Cancer </li></ul><ul><li>C hange in bowel or bladder habbits </li></ul><ul><li>A ny sore that does not heals </li></ul><ul><li>U nusual bleeding or discharge </li></ul><ul><li>T hickening or lump in breast or elsewhere </li></ul><ul><li> I ndigestion </li></ul><ul><li>O bvious change in wart or mole </li></ul><ul><li>N agging cough or hoarseness </li></ul><ul><li>U nexplained anemia </li></ul><ul><li>S udden and unexplained weight loss </li></ul>
  32. 33. <ul><li>2. Promoting risk factors awareness </li></ul><ul><li>3. Promoting healthy behaviors </li></ul><ul><li>Good nutrition and diet </li></ul><ul><li>Tomatoes, spinach, red wine, nuts, broccoli, oats, salmon, garlic, green tea, blueberries </li></ul><ul><li>Limiting alcohol consumption </li></ul><ul><li>Hepa B virus infant vaccination </li></ul><ul><li>Control of STDs </li></ul><ul><li>Changing risk behaviors </li></ul><ul><li>Teaching skills for early detection programs </li></ul><ul><li>Promoting participation in early detection programs </li></ul>
  33. 34. Cancer Screening <ul><li>-refers to detection of disease through tests, exams, and other procedures </li></ul><ul><li>An ocology nurse should have good hx taking skills. She shoukd be able to note down all possible clinical as well as behavioral clues through PE </li></ul>
  34. 35. DIAGNOSTIC TESTS <ul><li>Biopsy </li></ul><ul><li>- is the definitive means of diagnosing cancer and provides histological proof of malignancy. </li></ul><ul><li>- involves the surgical incision of a small piece of tissue of microscopic examination </li></ul><ul><li>Types: </li></ul><ul><li>a. Needle : Aspiration of Cells </li></ul><ul><li>b. Incisional : Removal of a wedge of suspected tissue from a larger mass </li></ul><ul><li>c. Excisional : Complete removal of the entire lesion </li></ul><ul><li>d. Staging : Multiple needle or incisional biopsies in tissues where metastasis is suspected or likely. </li></ul>
  35. 36. Other means of Detection <ul><li>Mammography </li></ul><ul><li>Papanicolaou’s (Pap) test </li></ul><ul><li>Stools for occult blood </li></ul><ul><li>Sigmoidoscopy </li></ul><ul><li>Colonospcopy </li></ul><ul><li>Skin Inspection </li></ul>
  36. 37. Types of Cancer
  37. 38. Testicular Cancer <ul><li>Arises from germinal epithelium from the sperm- producing germ cells or from nongerminal epithelium from other structures in testicles. </li></ul><ul><li>Testicular Cancer most often occurs between the ages of 15 and 40 </li></ul><ul><li>Metastasis occurs to the lung, liver, bone and adrenal glands. </li></ul><ul><li>Prevention : Routine Testicular Examination </li></ul>
  38. 39. Assessment <ul><li>Painless testicular swelling occurs. </li></ul><ul><li>Dragging sensation is evident in the scrotum. </li></ul><ul><li>Palpable lymphadenopathy, abdominal masses, and gynecomastia may indicate metastasis. </li></ul><ul><li>Late signs include back or bone pain and respiratory symptoms. </li></ul>
  39. 40. Interventions <ul><li>Prepare the client for radiation therapy or unlateral orcheictomy as prescribed . </li></ul><ul><li>Discuss reproduction, sexuality and fertility information and options with the client </li></ul><ul><li>For Post Op: </li></ul><ul><li>- Monitor for signs of bleeding and wound infection. </li></ul><ul><li>Monitor Intake and output </li></ul><ul><li>Notify the physician if chills, fever, increasing pain or tenderness at the incision site, or drainage of the incision occurs. </li></ul><ul><li>Instruct the client to perform a monthly testicular self-examination on the remaining testicle. </li></ul>
  40. 41. Cervical Cancer <ul><li>Pre-invasive cancer is limited to the cervix </li></ul><ul><li>Invasive cancer is in the cervix and other pelvic structures. </li></ul><ul><li>Metastasis usually is confined to the pelvis, but distant metastasis occurs through lymphatic spread. </li></ul><ul><li>Pre malignant changes are described on a continuum from dysplasia , which is the earliest premalignant change. </li></ul>
  41. 42. Precipitating Factors <ul><li>Low socioeconomic groups </li></ul><ul><li>Early first marriage </li></ul><ul><li>Early and frequent intercourse </li></ul><ul><li>Multiple sex partners </li></ul><ul><li>High parity </li></ul><ul><li>Poor hygiene </li></ul>
  42. 43. Screening and early detection <ul><li>The practice of good perineal needs must be emphasized </li></ul><ul><li>Avoid sex in an early age, avoid numerous partners, and practice the use of condom </li></ul><ul><li>Cancer warning signs: abnormal vaginal bleeding, and spotting after having sex </li></ul><ul><li>Early detection includes Pap smear for women over age 18. </li></ul>
  43. 44. Assessment <ul><li>Painless vaginal bleeding postmenstrually and postcoitally </li></ul><ul><li>Foul-smelling or serosanguineous vaginal discharge </li></ul><ul><li>Pelvic, lower back, leg or groin pain </li></ul><ul><li>Anorexia and weight loss </li></ul><ul><li>Leakage of urine and feces from the vagina </li></ul><ul><li>Dysuria </li></ul><ul><li>Hematuria </li></ul><ul><li>Cytological changes on Papanicolaou’s Test </li></ul>
  44. 45. Interventions <ul><li>Nonsurgical </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Cryosurgery </li></ul><ul><li>External Radiation </li></ul><ul><li>Internal Radiation Implants (Intracavitary) </li></ul><ul><li>Laser Therapy </li></ul><ul><li>Surgical </li></ul><ul><li>Conization </li></ul><ul><li>Hysterectomy </li></ul><ul><li>Pelvic Exenteration </li></ul>
  45. 46. Ovarian Cancer <ul><li>Ovarian cancer grows rapidly , spreads fast and is often bilateral. </li></ul><ul><li>Metastasis occurs by direct spread to the organs in the pelvis, by distal spread through lymphatic drainage or by peritoneal seeding </li></ul><ul><li>Prognosis is usually poor because the tumor usually is detected late. </li></ul><ul><li>An exploratory laparotomy is performed to diagnose and stage the tumor. </li></ul>
  46. 47. Assessment <ul><li>Abdominal discomfort or swelling </li></ul><ul><li>Gastrointestinal disturbances </li></ul><ul><li>Dysfunctional vaginal bleeding </li></ul><ul><li>Abdominal mass </li></ul>
  47. 48. Interventions <ul><li>External radiation is used if the tumor is invaded other organs. </li></ul><ul><li>Chemotherapy is used postoperatively for all stages of ovarian cancer. </li></ul><ul><li>Intraperitoneal chemotherapy involves the instillation of chemotherapy into the abdominal cavity. </li></ul><ul><li>Immunotherapy alters the immunological response of the ovary and promotes tumor resistance. </li></ul><ul><li>Total abdominal hysterectomy and bilateral salpingo-oophorectomy may be necessary. </li></ul>
  48. 49. Endometrial Cancer <ul><li>Is a slow growing tumor associated with the menopausal years. </li></ul><ul><li>Metastasis occurs through the lymphatic system to the ovaries and pelvis; via the blood to the lungs, liver and bone; or intraabdominally to the peritoneal cavity. </li></ul>
  49. 50. Precipitating Factors <ul><li>History of uterine polyps </li></ul><ul><li>Nulliparity </li></ul><ul><li>Polycystic ovary disease </li></ul><ul><li>Estrogen stimulation </li></ul><ul><li>Late menopause </li></ul><ul><li>Family history </li></ul>
  50. 51. Assessment <ul><li>- Postmenopausal bleeding </li></ul><ul><li>- Watery, serosanguineous discharge </li></ul><ul><li>- Low back, pelvic, or abdominal pain </li></ul><ul><li>- Enlarged uterus in advanced stages </li></ul>
  51. 52. Interventions <ul><li>Nonsurgical interventions </li></ul><ul><li>External radiation or internal radiation is used alone or in combination with surgery, depending on the stage of cancer. </li></ul><ul><li>Chemotherapy is used to treat advanced or recurrent disease. </li></ul><ul><li>Progestational therapy with medication such as medroxyprogesterone (Depo-Provera) or megestrol acetate (Megace) is used for estrogen dependent tumors. </li></ul><ul><li>Tamoxifen (Novaldex), an antiestrogen, also maybe prescribed. </li></ul><ul><li>Surgical interventions </li></ul><ul><li>Total abdominal hysterectomy and bilateral salpingo-oophorectomy </li></ul>
  52. 53. Breast Cancer <ul><li>Breast cancer is classified as invasive when it penetrates the tissue surrounding the mammary duct and grows in an irregular pattern. </li></ul><ul><li>Metastasis occurs via lymph nodes. </li></ul><ul><li>Common sites of metastasis are the bones, lungs; metastasis also occurs to the brain and liver. </li></ul><ul><li>Diagnosis is made by breast biopsy through a needle aspiration or by surgical removal of the tumor with microscopic examination for malignant cells. </li></ul><ul><li>Prevention : Monthly BSE </li></ul>
  53. 54. Precipitating Factors <ul><li>Family history </li></ul><ul><li>Early menarche and late menopause </li></ul><ul><li>Previous cancer of the breast, uterus or ovaries </li></ul><ul><li>Nulliparity </li></ul><ul><li>Obesity </li></ul><ul><li>High dose radiation exposure to chest </li></ul><ul><li>High fat diet </li></ul>
  54. 55. Guideline prevention, screening and early detection <ul><li>Advice clients to reduce the amount of fat in the diet. Early detection includes: </li></ul><ul><li>BSE once a month </li></ul><ul><li>Yearly breast exam by a health care provider </li></ul><ul><li>Baseline mammogram b/w the ages 35-39 </li></ul><ul><li>Yearly mammogram after the age 40(if with family hx of breast Ca, mammogram should be started at age 30) </li></ul>
  55. 56. Assessment <ul><li>Mass felt during BSE </li></ul><ul><li>Mass usually felt in the upper outer quadrant or beneath the nipple. </li></ul><ul><li>A fixed, irregular noncapsulated mass </li></ul><ul><li>A painless mass except in late stages </li></ul><ul><li>Nipple retraction or elevation </li></ul><ul><li>Asymmetry, with affected breast being higher </li></ul><ul><li>Bloody or clear nipple discharge </li></ul><ul><li>Skin dimpling, retraction, or ulceration </li></ul><ul><li>Skin edema or peau d’ orange skin </li></ul><ul><li>Axillary lymphadenopathy </li></ul><ul><li>Lymphedema of the affected arm </li></ul><ul><li>Symptoms of bone and lungs metastasis </li></ul><ul><li>Presence of the lesions on mammography </li></ul>
  56. 57. Nonsurgical Interventions <ul><li>Chemotherapy </li></ul><ul><li>Radiation therapy </li></ul><ul><li>Hormonal manipulation via the use of medication in postmenopausal women or other medications such as tamoxifen (Novadex) for estrogen receptor positiv tumors </li></ul>
  57. 58. Surgical Interventions <ul><li>Surgical breast procedures with possible breast reconstruction </li></ul><ul><li>Oophorectomy for estrogen receptor – positive tumors </li></ul><ul><li>Ablative therapy with adrenalectomy or chemical ablation, which blocks the production of cortisol, androstenedione, and aldosterone. </li></ul>
  58. 59. Gastric Cancer <ul><li>Gastric cancer is a malignant growth in the stomach. </li></ul>
  59. 60. Risk Factors <ul><li>Diet high in complex carbohydrates , grains and salt, and low in fresh, green leafy vegetables and fresh fruit </li></ul><ul><li>Smoking </li></ul><ul><li>Alcohol ingestion </li></ul><ul><li>The use of nitrates </li></ul><ul><li>History of gastric ulcers </li></ul>
  60. 61. Assessment <ul><li>Fatigue </li></ul><ul><li>Anorexia and weight loss </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Indigestion and epigastric discomfort </li></ul><ul><li>A sensation of pressure in the stomach </li></ul><ul><li>Dysphagia </li></ul><ul><li>Anemia </li></ul><ul><li>Ascites </li></ul><ul><li>Palpable mass </li></ul>
  61. 62. Interventions <ul><li>Monitor vital signs. </li></ul><ul><li>Monitor hemoglobin and hematocrit and administer blood transfusions as prescribed. </li></ul><ul><li>Monitor weight. </li></ul><ul><li>Assess nutritional status; encourage small, bland, easily digestible meals with vitamin and mineral supplements. </li></ul><ul><li>Administer pain medications as prescribed. </li></ul><ul><li>Prepare the client for chemotherapy or radiation as prescribed. </li></ul><ul><li>Prepare the client for surgical resection of the tumor as prescribed. </li></ul>
  62. 63. Surgical Interventions <ul><li>Subtotal Gastrectomy </li></ul><ul><li>Billroth I </li></ul><ul><li>- also called gastroduodenostomy </li></ul><ul><li>- partial gastrectomy, with remaining segment anastomosed to the duodenum </li></ul><ul><li>Billroth II </li></ul><ul><li>- also called gastrojejunostomy </li></ul><ul><li>- partial gastrectomy, with remaining segment anastomosed to the jejunum. </li></ul><ul><li>Total Gastrectomy </li></ul><ul><li>- Also called esophagojejunostomy </li></ul><ul><li>- removal of the stomach with attachment of the esophagus to the jejunum or duodenum. </li></ul>
  63. 64. Pancreatic Cancer <ul><li>Is the most common neoplasm affecting the pancreas. </li></ul><ul><li>The occurrence of pancreatic cancer has been linked to diabetes mellitus, alcohol use, history of previous pancreatitis, smoking, ingestion of high fat diet, and exposure to environmental chemicals. </li></ul><ul><li>Symptoms usually do not occur until the tumor is large; therefore the prognosis is poor. </li></ul>
  64. 65. Assessment <ul><li>Nausea and vomiting </li></ul><ul><li>Jaundice </li></ul><ul><li>Unexplained weight loss </li></ul><ul><li>Clay-colored stools </li></ul><ul><li>Glucose intolerance </li></ul><ul><li>Abdominal pain </li></ul>
  65. 66. Interventions <ul><li>Radiation </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Whipple’s procedure, which involves a pancreaticoduodenectomy with removal of the distal third of the stomach, pancreaticojejunostomy, gastrojejunostomy and choledochojejunostomy </li></ul><ul><li>Postoperative care measures are similar to care of a client with pancreatiitis and the client following gastric surgery. </li></ul>
  66. 67. Intestinal Tumors <ul><li>Intestinal tumors are malignant lesions that develop as polyps in the colon or rectum. </li></ul><ul><li>Complications include bowel perforation with peritonitis, abscess and fistula formation, hemorrhage and complete intestinal obstruction. </li></ul><ul><li>Metastasis occurs via the circulatory or lymphatic system or by direct extension to other areas in the colon or other organs. </li></ul>
  67. 68. Assessment <ul><li>Blood in the stools </li></ul><ul><li>Anorexia, vomiting and weight loss </li></ul><ul><li>Malaise </li></ul><ul><li>Anemia </li></ul><ul><li>Abnormal stools </li></ul><ul><ul><li>Ascending colon tumor : Diarrhea </li></ul></ul><ul><ul><li>Descending colon tumor : Constipation or some diarrhea, or flat ribbonlike stool resulting from partial obstruction </li></ul></ul><ul><ul><li>Rectal tumor : Alternating constipation and diarrhea </li></ul></ul><ul><li>Guarding or abdominal distention </li></ul><ul><li>Abdominal mass (late sign) </li></ul><ul><li>Cachexia (late sign) </li></ul>
  68. 69. Interventions <ul><li>Monitor for signs of complications, which include bowel perforation with peritonitis, abscess or fistula formation, hemorrhage and complete intestinal obstruction. </li></ul><ul><li>Monitor for signs of bowel perforation, which include low blood pressure, rapid and weak pulse, distended abdomen and elevated temperature. </li></ul><ul><li>Note that an early sign of intestinal obstruction is increased in peristaltic activity, which produces an increased in bowel sound; as the obstruction progresses, hypoactive sounds are heard </li></ul><ul><li>Prepare for radiation preoperatively to facilitate surgical resection, and postoperatively to decrease the risk of recurrence or to reduce pain , hemorrhage, bowel obstruction, or metastasis. </li></ul><ul><li>Chemotherapy is used postoperatively to assist in the control of symptoms and the spread of the disease. </li></ul>
  69. 70. Colon Cancer <ul><li>Colon cancer is cancer of the large intestine (colon), the lower part of your digestive system </li></ul><ul><li>Most cases of colon cancer begin as small, noncancerous (benign) clumps of cells called adenomatous polyps. Over time some of these polyps become colon cancers. </li></ul>
  70. 71. Assessment: <ul><li>A change in your bowel habits, including diarrhea or constipation or a change in the consistency of your stool for more than a couple of weeks </li></ul><ul><li>Rectal bleeding or blood in your stool </li></ul><ul><li>Persistent abdominal discomfort, such as cramps, gas or pain </li></ul><ul><li>Abdominal pain with a bowel movement </li></ul><ul><li>A feeling that your bowel doesn't empty completely </li></ul><ul><li>Weakness or fatigue </li></ul><ul><li>Unexplained weight loss </li></ul>
  71. 72. <ul><li>Age. </li></ul><ul><li>A personal history of colorectal cancer or polyps. </li></ul><ul><li>Inflammatory intestinal conditions. </li></ul><ul><li>Inherited disorders that affect the colon. </li></ul><ul><li>Family history of colon cancer and colon polyps. </li></ul><ul><li>Diet low in fiber and high in fat and calories. </li></ul><ul><li>A sedentary lifestyle. </li></ul><ul><li>Diabetes. </li></ul><ul><li>Obesity. </li></ul><ul><li>Smoking. </li></ul><ul><li>Alcohol. </li></ul><ul><li>Radiation therapy for cancer. </li></ul>Risk factors:
  72. 73. <ul><li>Colorectal Ca </li></ul><ul><li>Cancer signs: rectal bleeding, change in stools, pain in the abdomen, and pressure on the rectum </li></ul><ul><li>Early detection includes an annual digital rectal exam starting at age 40, an annual stool blood test starting age 50 and an annual inspection of the colon (sigmoidoscopy) at the age 50 </li></ul>Screening and early detection
  73. 74. Lung Cancer <ul><li>Is a malignant tumor of the lung that may be primary or metastatic. </li></ul><ul><li>The lungs are the common target of metastasis. </li></ul><ul><li>Bronchiogenic carcinoma spreads through direct extension and lymphatic dissemination. </li></ul><ul><li>The four major types of lung cancer include small cell (oat cell), epidermal (squamous cell), adenocarcinoma, and large cell anaplastic carcinoma. </li></ul>
  74. 75. Diagnosis <ul><li>Diagnosis is made by a chest x-ray, which will show a lesion or mass, and bronhoscopy and sputum studies, which will demonstrate a positive cytological study for cancer cells. </li></ul>
  75. 76. Causes <ul><li>Cigarette smoking </li></ul><ul><li>Exposure to environmental pollutants </li></ul><ul><li>Exposure to occupational pollutants </li></ul>
  76. 77. Screening and early detection <ul><li>“ do not smoke” is an important msg </li></ul><ul><li>Guidelines to reduce exposure to cancer-causing substances in workplaces should be followed </li></ul>
  77. 78. Assessment <ul><li>dyspnea (shortness of breath) </li></ul><ul><li>hemoptysis (coughing up blood) </li></ul><ul><li>chronic coughing or change in regular coughing pattern </li></ul><ul><li>wheezing </li></ul><ul><li>chest pain or pain in the abdomen </li></ul><ul><li>cachexia (weight loss), fatigue and loss of appetite </li></ul><ul><li>dysphonia (hoarse voice) </li></ul><ul><li>clubbing of the fingernails (uncommon) </li></ul><ul><li>dysphagia (difficulty swallowing). </li></ul>
  78. 79. Interventions <ul><li>Monitor vital signs. </li></ul><ul><li>Monitor breathing patterns and breath sounds and for signs of respiratory impairment. </li></ul><ul><li>Assess for tracheal deviation </li></ul><ul><li>Administer analgesics as prescribed for pain management. </li></ul><ul><li>Place in Fowler’s position for ease in breathing. </li></ul><ul><li>Administer oxygen as prescribed and humidification to moisten and loosen secretions. </li></ul><ul><li>Monitor pulse oximetry. </li></ul><ul><li>Provide respiratory treatments as prescribed. </li></ul><ul><li>Administer bronchodilators and corticosteroids as prescribed to decrease bronchospasm , inflammation and edema. </li></ul><ul><li>Provide a high-calorie, high protein, high vitamin diet. </li></ul><ul><li>Provide activity as tolerated , rest periods and active and passive range-of-motion exercises. </li></ul><ul><li>Monitor for bleeding, infection and electrolyte imbalances. </li></ul>
  79. 80. Laryngeal Cancer <ul><li>Laryngeal cancer is a malignant tumor of the larynx. </li></ul><ul><li>Laryngeal cancer presents as malignant ulcerations with underlying infiltration. </li></ul><ul><li>Metastasis to the lungs is common. </li></ul><ul><li>Diagnosis is made by laryngoscopy and biopsy showing a positive cytological study for cancer cells. </li></ul>
  80. 81. Causes <ul><li>Cigarette smoking </li></ul><ul><li>Exposure to environmental pollutants </li></ul><ul><li>Exposure to radiation </li></ul><ul><li>Voice strain </li></ul>
  81. 82. Assessment <ul><li>Persistent hoarseness and sore throat </li></ul><ul><li>Painless neck mass </li></ul><ul><li>A feeling of a lump in the throat </li></ul><ul><li>Burning sensation in the throat </li></ul><ul><li>Dysphasia </li></ul><ul><li>Change in voice quality </li></ul><ul><li>Dyspnea </li></ul><ul><li>Weakness and weightloss </li></ul><ul><li>Hemopytysis </li></ul><ul><li>Foul breath odor </li></ul>
  82. 83. Interventions <ul><li>Place in Fowler’s position to promote optimal air exchange. </li></ul><ul><li>Monitor respiratory status. </li></ul><ul><li>Monitor for signs of aspiration of food and fluids. </li></ul><ul><li>Administer oxygen as prescribed. </li></ul><ul><li>Provide respiratory treatments as prescribed. </li></ul><ul><li>Provide activity as tolerated. </li></ul><ul><li>Provide a high-calorie, high-protein, high-vitamin diet. </li></ul><ul><li>Provide nutritional support via total parenteral nutrition, nasogastric tube feedings, gastrostomy or jejunostomy tube as prescribed. </li></ul><ul><li>Administer analgesics as prescribed for pain. </li></ul>
  83. 84. Prostate Cancer <ul><li>This slow-growing cancer of the prostate gland is usually a Androgen dependent type of carcinoma. </li></ul><ul><li>The risks increases in men with each decade after age 50. </li></ul><ul><li>Prostate cancer can spread via direct invasion of surrounding tissuesor by metastasis, through the bloodstream and lymphatics, to the bony pelvis and spine. </li></ul><ul><li>Bone metastasis is a concern. </li></ul>
  84. 85. Assessment <ul><li>Asymptomatic </li></ul><ul><li>Hard, pea-sized nodule palpated on rectal examination. </li></ul><ul><li>Hematuria </li></ul><ul><li>Late symptoms such as weightloss, urinary obstruction, and pain radiating form the lumbosacral area down the leg. </li></ul><ul><li>Prostatic-specific antigen test is not necessarily an indicator of malignancy and use is routine to monitor the client’s response to therapy </li></ul><ul><li>Spread and mestastasis is indicated by elevated serum acid and phosphatase. </li></ul>
  85. 86. Risk Factors: <ul><li>Age. </li></ul><ul><li>Race or ethnicity. </li></ul><ul><li>Family history. </li></ul><ul><li>High-fat diet </li></ul><ul><li>High testosterone levels. </li></ul><ul><li>Occupations exposed to harmful chemicals </li></ul>
  86. 87. Screening and early detection <ul><li>There are no preventive guidelines </li></ul><ul><li>Early detection includes an annual digital rectal exam at age 40 </li></ul>
  87. 88. Interventions <ul><li>Non-surgical </li></ul><ul><li>1. Prepare the client for hormone manipulation therapy as prescribed. </li></ul><ul><li>2. Prepare the client for radiation therapy, which may be prescribed alone or along with surgery and may be prescribed pre-operatively or post-operatively to reduce the lesion and limit metastasis. </li></ul><ul><li>3. Prepare the client for the administration of chemotherapy in cases of hormone-resistant tumors. </li></ul><ul><li>Surgical </li></ul><ul><li>1. TURP </li></ul><ul><li>2. Suprapubic Prostatectomy </li></ul><ul><li>3. Retropubic Prostatectomy </li></ul><ul><li>4. Perineal Prostatectomy </li></ul>
  88. 89. Skin Cancer <ul><li>Is a malignant lesion of the skin, which may or may not metastasize. </li></ul><ul><li>Causes include chronic friction and irritation to a skin area and exposure to ultraviolet rays . </li></ul><ul><li>Diagnosis : </li></ul><ul><li>Is confirmed by a skin biopsy that is positive for cancer cells. </li></ul>
  89. 90. Types of Skin Cancer <ul><li>Basal cell – the most common type of skin cancer, basal cell cancer arises from the basal cells contained in the epidermis. </li></ul><ul><li>Squamous cell – the second most common type of skin cancer in whites, it is a tumor of the epidermal keratinocytes and can infiltrate surrounding structures, metastasize to lymphnodes, and be subsequently fatal. </li></ul><ul><li>Malignant melanoma – cancer of the melanocytes, can metastasize to the brain , lungs, bone, liver and skin. </li></ul>
  90. 91. Assessment <ul><li>Change in color, size, or shape of pre existing lesions </li></ul><ul><li>Pruritus </li></ul><ul><li>Local Soreness </li></ul><ul><li>Appearance of Skin Cancer Lesions: </li></ul><ul><li>A waxy nodule </li></ul><ul><li>An irregular, circular, bordered lesions with hues of tan, black, or blue </li></ul><ul><li>A small, red, nodular lesion </li></ul><ul><li>An oozing, bleeding, crusting lesion </li></ul>
  91. 92. Nursing Interventions <ul><li>Instruct the client regarding preventive measures. </li></ul><ul><li>Instruct the client to monitor for lesions that do not heal or that change characteristics. </li></ul><ul><li>Instruct the client to have moles or lesions removed that are subject ot chronic irritation. </li></ul><ul><li>Instruct the client to avoid contact with chemical irritants. </li></ul><ul><li>Intsruct the client to wear layered clothing and use sun screening lotions with an appropriate skin protection factor when outdoors. </li></ul><ul><li>Instruct the client to avoid sun exposure between 11 am to 3 pm. </li></ul><ul><li>Assist with surgical excision of the lesion as prescribed. </li></ul>
  92. 93. Leukemia <ul><li>A malignant exacerbation in the number of leukocytes, usually at an immature stage, in the bone marrow. </li></ul><ul><li>May be acute, with a sudden onset and short duration, or chronic, with a slow onset and persistent symptoms over a period of years. </li></ul><ul><li>Leukemia affects the bone marrow causing anemia, leukopenia, the production of immature cells, thrombocytopenia and a decline in immunity. </li></ul><ul><li>The Cause is unknown and appears to involve gene damage of cells, leading to the transformation of cells from a normal state to a malignant state. </li></ul>
  93. 94. <ul><li>Risk Factors : </li></ul><ul><li>Genetic </li></ul><ul><li>Viral </li></ul><ul><li>Immunological </li></ul><ul><li>Environmental factors </li></ul><ul><li>Exposure to radiation </li></ul><ul><li>Medications </li></ul>
  94. 95. Classification of Leukemia <ul><li>Acute Lymphocytic Leukemia – mostly lymphoblasts , age of onset is less than 15 years. </li></ul><ul><li>Acute Myelogenous Leukemia – mostly myeloblasts present in bone marrow, age of onset is between 15 and 39 years </li></ul><ul><li>Chronic Myelogenous Leukemia – mostly granulocytes present in bone marrow, age of onset is after 50 years </li></ul><ul><li>Chronic Lymphocytic Leukemia – mostly lymphocytes present in bone marrow, age of onset is after 50 years </li></ul>
  95. 96. Assessment <ul><li>Anorexia, fatigue, weakness, weight loss </li></ul><ul><li>Anemia </li></ul><ul><li>Bleeding (nosebleeds, gum bleeding, rectal bleeding, increased menstrual flow) </li></ul><ul><li>Petechiae </li></ul><ul><li>Prolonged bleeding after minor abrasions or lacerations </li></ul><ul><li>Elevated Temperature </li></ul><ul><li>Lymphadenopathy and splenomegaly </li></ul><ul><li>Palpitations, tachycardia, orthostatic hypotension </li></ul><ul><li>Pallor, dyspnea on exertion </li></ul><ul><li>Headache </li></ul><ul><li>Bone pain and joint swelling </li></ul><ul><li>Normal, elevated or reduced white blood cell count </li></ul><ul><li>Decreased hemoglobin and hematocrit levels </li></ul><ul><li>Decreased platelet </li></ul><ul><li>Positive bone marrow biopsy identifying leukemic blast phase cells </li></ul>
  96. 97. Hodgkin’s Disease <ul><li>Is a malignancy of the lymph nodes that originates in a single lymph node or a single chain of nodes. </li></ul><ul><li>The disease usually involves lymph nodes, tonsils, spleen, and bone marrow and is characterized by the presence of the Reed-Sternberg cell in the nodes. </li></ul><ul><li>Possible causes include viral infections and previous exposure to alkylating chemical agents. </li></ul>
  97. 98. Staging in Hodgkin’s Disease <ul><li>Stage I </li></ul><ul><li>Involvement of s single lymph node region or an extra lymphatic organ or site </li></ul><ul><li>Stage II </li></ul><ul><li>Involvement of two or more lymph node regions on the same side of the diaphragm or localized involvement of an extralymphatic organ or site </li></ul><ul><li>Stage III </li></ul><ul><li>Involvement of lymph node regions on both side of the diaphragm </li></ul><ul><li>Stage IV </li></ul><ul><li>Diffuse or disseminated involvement of one or more extralymphatic organs with or without associated lymph node involvement </li></ul>
  98. 99. Assessment <ul><li>Fever </li></ul><ul><li>Malaise, fatigue, and weakness </li></ul><ul><li>Night sweats </li></ul><ul><li>Loss of appetite and significant weight loss </li></ul><ul><li>Anemia and thrombocytopenia </li></ul><ul><li>Enlarged lymph nodes, spleen and liver </li></ul><ul><li>Positive biopsy of lymph nodes, with cervical nodes most often affected first </li></ul><ul><li>Presence of Reed-Sternberg cells in nodes </li></ul><ul><li>Positive computed tomography scan of the liver and spleen </li></ul>
  99. 100. Nursing Interventions <ul><li>For Stages I and II without mediastinal node involvement, the treatment of choice is extensive external radiation of the involved lymph node regions. </li></ul><ul><li>With more extensive disease, radiation along with multi agent chemotherapy is used. </li></ul><ul><li>Monitor for side effects related to chemotherapy or radiation therapy. </li></ul><ul><li>Monitor for signs of infection and bleeding. </li></ul><ul><li>Maintain infections and bleeding precautions. </li></ul><ul><li>Discuss the possibility of sterility with the male client receiving radiation, and inform the client of options related to sperm banks </li></ul>
  100. 101. Multiple Myeloma <ul><li>A malignant proliferation of plasma cells and tumors within the bone. </li></ul><ul><li>An excessive number of abnormal, plasma cells invade the bone marrow, develop into tumors , and ultimately destroy bone; invasion of the lymph node, spleen, and liver occurs. </li></ul><ul><li>The abnormal plasma cells produce an abnormal antibody (myeloma protein or Bence Jones protein) that is found in the blood and urine. </li></ul>
  101. 102. Assessment <ul><li>Bone pain, especially in the pelvis, spine and ribs </li></ul><ul><li>Weakness and fatigue </li></ul><ul><li>Recurrent infections </li></ul><ul><li>Anemia </li></ul><ul><li>Bence Jones proteinuria and elevated total serum protein level </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Thrombocytopenia and Granulocytopenia </li></ul><ul><li>Elevated calcium and uric acid levels </li></ul><ul><li>Renal failure </li></ul><ul><li>Spinal cord compression and paraplegia </li></ul>
  102. 103. Interventions <ul><li>Monitor for signs of bleeding, infection, and skeletal fractures. </li></ul><ul><li>Encourage fluids up to 3 to 4 L a day to offset potential problems associated with hypercalcemia, hyperuricemia and proteinuria. </li></ul><ul><li>Encourage ambulation to prevent renal problems and to slow down bone resorption. </li></ul><ul><li>Provide skeletal support during moving, turning and ambulating to prevent pathological fractures </li></ul><ul><li>Provide a hazard –free enviroment. </li></ul><ul><li>Instruct the client in home care measures and the signs and symptoms of infection. </li></ul>