Medical-Surgical Nursing 2 Prepared by Dr. Peña and Dr. Cabigon

Oncology: Nursing Management of Patients with Cancer

Definition of Terms

A. Neoplasia – new, altered and abnormal development of cells that may be benign or malignantB. Tumor – mass or swelling in or on the bodyC. Anaplasia – means lack of differentiationD. Biopsy – the removal & examination of tissue from the living bodyE. Carcinogenesis – development of cancerous cells from normal onesF. Carcinoma – any malignant tumor derived from epithelial tissueG. Chemotherapy – treatment of disease, especially cancer, by means of chemical agents/drugsH. Dysplasia – means deranged development, disordered maturationI. Hyperplasia – constitutes an increase in the number of cells in organ or tissue, which may then have increased

volumeJ. Proliferation- refers to the process of cell renewal or replacement. In cancer, proliferation process continues without

the normal control mechanisms.K. Differentiation- refers to the process by which cells diversify, acquire specific structural and functional

characteristics and mature. Cells in cancer are poorly differentiated.

CHARACTERISTICS OF BENIGN & MALIGNANT NEOPLASM

Characteristics Benign MalignantSpeed of Growth Grows slowly Grows rapidlyMode of Growth Remains localized Infiltrates surrounding tissuesCapsule Encapsulated Not encapsulatedCell characteristics Well differentiated Poorly differentiatedRecurrences Extremely unusual Common following surgeryMetastasis Never occur Very commonEffect of neoplasm Not harmful to host Always harmfulPrognosis Very good prognosis Poor prognosis

*[Tip]: Characteristics of Benign neoplasms – “NEWSLUG”, Non-metastatic, Encapsulated, Well-differentiated, Slow growth, Localized, Unusual recurrence, Good prognosis

Agents that can Predispose to Cancer

A. Chemical carcinogens These act by causing cell mutation or alteration in cell enzymes & proteins causing altered cell replication. Tobacco – associated with a number of cancers, particularly cancers of the lung, larynx, mouth, esophageal,

stomach, pancreas, kidney, bladder and cervix Ether and coal tar – are also associated with lung cancer Asbestos – associated with lung cancer and mesothelioma (cancer that affects the thin membranes lining the

abdomen and chest) Benzene – associated with leukemias and Hodgkin lymphoma Some other examples are: Industrial compounds (i.e. arsenic, beryllium, cadmium), Spoilt Foods, and

preservatives like nitrites. B. Physical Agents

Physical irritation/trauma Radiation (x-rays, gamma and ultraviolet radiation) from diagnostic or therapeutic x-rays, radioisotopes,

sunlight These will usually cause cancer after long time of exposure and interaction

C. Genetics The human DNA has specific genes for cancer called Oncogene. When this gene is exposed to carcinogens,

there will be changes in cell structure, and growth behavior, leading to become malignant cells. D. Viruses – these viruses are called oncogenic viruses. They infect the host DNA or RNA resulting in cell mutation.

DNA viruses:1. Hepa B (HBV) – associated with hepatocellular carcinoma 2. Herpes simplex virus (HSV) – associated with Kaposi’s sarcoma (a type of skin cancer typically in AIDS

patient)3. Human papillomavirus (HPV) – can lead to cancers of cervix, anus and penis 4. Epstein Barr virus (EBV) – associated with lymphoma

5. Merkel cell Polyomavirus (MCV) – associated with the development of Merkel cell carcinoma (rare but aggressive form of skin cancer)

RNA viruses 1. Human T-lymphotropic virus (HTLV) – associated with leukemia2. Hepa C viruses (HCV) – associated with hepatocellular carcinoma

E. Immune system alterations – as seen in patients with immunodeficiency disease, the elderly and those receiving immunosuppressant drugs.

F. Hormonal factors – hormones make the cell more sensitive to the process of carcinogenesis or may encourage the growth and spread of an established tumor

Breast cancer – associated with increased estrogen levels in the body (nulliparity, early menarch, late menopause, obesity, estrogen replacement therapy, estrogen-containing contraceptives)

Endometrial cancer – also associated with increased levels of estrogen (nulliparity, early menarch, late menopause, obesity, estrogen replacement therapy)

Ovarian cancer – associated with exposure to exogenous female sex hormones (estrogen replacement therapy and long-acting hormonal contraceptives)

Oral contraceptives – decrease risk of ovarian and endometrial cancers, but increase risk of breast cancer Estrogen replacement therapy – increases risk of breast, ovarian, endometrial and brain cancers Prostate cancer – the androgen receptor helps prostate cancer cells to survive

G. Dietary factors High fat diet and low fiber intake for colon cancer Cooking food at high temperatures, for example grilling or barbecuing meats, can lead to the formation of

minute quantities of many potent carcinogens that are comparable to those found in cigarette smoke Aflatoxin (produced by the mold Aspergillus that colonizes nuts and grains) can lead to liver cancer Other dietary carcinogens – nitrosamines (from processed foods, like hotdogs and bacons), acryl amides

(from deep-fried foods) and trans-fat or unsaturated fat (from fast food, snack food, fried food)

Predisposing FactorsA. Age – older people are more prone. This is a very important factor for cancer development. B. Sex – women for breast, men for prostateC. Urban versus Rural residenceD. Geographic distributionE. OccupationF. HeredityG. StressH. Precancerous lesions – these can lead to transformation into cancer

Actinic keratosis or solar keratosis – thick, scaly, or crusty patches of skin; may progress to squamous cell carcinoma

Barrett's esophagus – an abnormal change (metaplasia) in the cells of the inferior portion of the esophagus; may progress to esophageal cancer

Atrophic gastritis – chronic inflammation of the stomach mucosa, leading to loss of gastric glandular cells and their eventual replacement by intestinal and fibrous tissues; may progress to gastric carcinoma

Cervical dysplasia or Cervical intraepithelial neoplasia (CIN) – abnormal growth (dysplasia) of squamous cells on the surface of the cervix; may progress to cervical cancer

I. Obesity (breast and colorectal)

Warning Signals of Cancer (CAUTION) by the American Cancer Society (ACS)

C – Change in bowel or bladder habitsA – A sore that does not healU – Unusual bleeding/discharge; unexplained anemia and sudden weight lossT – Thickening or lumps in breast or elsewhereI – Indigestion or difficulty of swallowingO – Obvious change in wart or moleN – Nagging cough or hoarseness of voice

Sites of Cancer and Danger SignalsA. Breast – lump, thickening, dimpling in breast; unusual size and shape of breast; one breast unusually lower;

retraction, sore or bleeding in the nippleB. Colon & rectum – change in bowel habits/bleedingC. Kidney & bladder – urinary difficulty/bleedingD. Lung – persistent cough/lingering respiratory ailmentE. Prostate – urinary difficultyF. Mouth, larynx & pharynx – sore that does not heal, difficulty in swallowing & hoarseness

G. Skin – sore that does not heal, change in wart or moleH. Stomach – indigestionI. Uterus – unusual bleeding or discharge

Top 3 Leading Types of CancersA. Male

1. Prostate2. Lung and Bronchus – most mortality3. Colon and Rectum

B. Female1. Breast2. Cervical – 2nd in the Philippines3. Lung and Bronchus – most mortality

Metastasis – pathways of spread:A. Direct seeding of body cavities or surfaces – whenever malignant neoplasm penetrates into a natural “open field”;

involves peritoneal cavity (most often), pleural, pericardial, subarachnoid space and jointsB. Lymphatic spread – pattern of lymph node involvement follows the natural route of drainage; this is the most common

mode of spreadC. Hematogenous spread – malignant cells are disseminated through the blood stream; Liver & lungs – most frequently

involved in hematogenous disseminationD. Direct transplantation of tumor cells (ex: on surgical instrument) – theoretically, it can occur but exceedingly rare

Tumor StagingStage I – malignant cells confined to tissue of originStage II – limited local spreading to near lymph nodesStage III – tumor is larger, or spread into nearby tissue, or both; regional lymph nodes affectedStage IV – metastasis to distant parts of the body

TNM Classification – specifies the extent of the primary tumor (T), extent of regional lymph node metastasis (N) and absence or presence of distant metastasis (M)

A. Primary Tumor (T) Tx – primary tumor cannot be assessed T0 – no evidence of primary tumor Tis – carcinoma in situ T1, T2, T3, T4 – increasing size and/or local extent of the primary tumor

B. Regional Lymph Nodes (N) Nx – regional lymph nodes cannot be assessed N0 – no regional lymph node metastasis N1, N2, N3 – increasing involvement of regional lymph nodes

C. Distant Metastasis (M) Mx – distant metastasis cannot be assessed M0 – no distant metastasis M1 – distant metastasis

Goals of Cancer TherapyA. Cure – the aim of this modality is to make sure that the client will be disease-free & live normal expectancyB. Control – not curing but controlling by therapy over long periods of timeC. Palliative – cure & control not possible; but maintain quality of life as high as possible

Therapeutic ModalitiesA. Surgery

Preventive – removal of precancerous lesions/benign tumors Diagnostic – biopsy Curative – removal of an entire tumor (en bloc resection) Reconstructive – improvement of structure/function of an organ Palliative – relief of distressing signs & symptoms (ex. oophorectomy w/ breast cancer to reduce estrogen

secretion retarding metastasis)B. Chemotherapy – this involves administering cytotoxic drug to intervene and interrupt the cell cycleC. Immunotherapy or biotherapy – involves treatment with agents derived from biologic sources or with agents that

affect biologic responses like interferons, interleukins, and monoclonal antibodiesD. Radiotherapy – used for radiosensitive cancers like skin cancer, head and neck tumors, cervical cancer, seminoma

and early stage Hodgkin’s; the response of the cancer cells depend on the type and phase of cell cycle

Chemotherapy – use of drugs to retard the growth of or destroy cancerous cells; use to cure, for palliation, combined w/ surgery, combined with radiation

A. Classification Cell-cycle specific: attack cells at a specific point in the process of cell division Cell-cycle non-specific: act at one time during cell division

B. Administration IV – most common route Arterial infusion - direct Regional perfusion Intraperitoneal Oral, IM (less common)

Nursing Interventions for General Chemotherapeutic Side Effects

A. GI system (NDx: Imbalanced Nutrition: Less than body requirements; Impaired oral mucous membranes) N & V. Antiemetic are given; withhold food/fluid before start of chemo Diarrhea. Replace fluid-electrolyte losses, low-fiber diet Constipation. Increased fluid intake & fibers Anorexia. Encourage high protein and high calorie diet, serve food in ways to make it appealing small frequent

feedings, avoid giving fluids while eating; light exercise before meals to stimulate appetite; red meats may taste bitter (use of plastic utensils may help)

Xerostomia (dry mouth). Ice chips, hard candy, gentle mouth care with 1/2 strength non alcohol mouth wash and water

Stomatitis. Provide good oral care; avoid hot & spicy food; eat soft foods; soft toothbrush, Rinse with normal saline or sodium bicarbonate (baking soda) 4x/day; Avoid ALCOHOL-based rinses

Drug-food interaction. Specific antineoplastics can have serious interactions with food; foods high in Tryamine (aged cheese, beer, bananas, caffeine, yogurt and liver) cause hypertensive crises when eaten after taking procarbazine

B. Integumentary system (NDx: Impaired skin integrity, Disturbed body image) Pruritus, urticaria. Provide good skin care Drying and flaking of skin. Handle skin gently; Do NOT rub affected area; Lotion may be applied; Wash skin only

with SOAP and Water Alopecia/skin pigmentation/nail changes. Reassure that it is temporary & encourage to wear wigs, hats, or head

scarf; but anticipate change in texture and color; alopecia begins within 2 weeks of therapy and regrowth within 8 weeks of termination

C. Hematopoeitic (NDx: Risk for injury, Risk for infection) Anemia. Provide frequent rest periods Neutropenia. Protect from infection; Avoid people with infection, crowds; neutropenic precautions—private room,

maintain aseptic technique and strict hand washing, fresh flowers, fruits and vegetables are prohibited because they harbor bacteria; Avoid frequent invasive procedures; Fever is the most important sign; Administer prescribed antibiotics X 2weeks

Bleeding. Thrombocytopenia (<100,000) is the most common cause; <20, 000à spontaneous bleeding; Protect from trauma; Avoid ASA; Use soft toothbrush; Use electric razor; Avoid frequent IM, IV, rectal and catheterization; Soft foods and stool softeners

D. Genito-Urinary system Urine color changes. Reassure that it is harmless Nephrotoxicity. Some chemotherapeutic agents can damage the kidneys; monitor BUN and creatinine

E. Reproductive system Premature menopause/amenorrhea. Reassure menstruation resumes after chemotherapy Sterility and impotence. May be temporary or permanent; may advise men to bank sperm

F. Miscellaneous Fatigue. Plan daily activities to allow alternating rest periods; Light exercise is encouraged; Small frequent meals

Chemotherapeutic Agents – drugs that act to destroy rapidly dividing cellsA. Alkylating agents – cell-cycle nonspecific

Ex. cyclophosphamide, cisplatin, ifosfamide, busulfan, carboplatin, chlorambucil SE: hemorrhagic cystitis (cyclophosphamide) and renal toxicity (cisplatin)

B. Nitrosureas – similar to alkalating agents; cross the blood-brain barrier Ex. carmustine, lomustine and steptozocin

C. Antitumor antibiotics – cell-cycle nonspecific Ex. doxorubicin, daunorubicin, bleomycin, plicamycin SE: cardiac toxicity (doxorubicin, daunorubicin)

D. Antimetabolites – cell-cycle specific (S phase) Ex. methotrexate, 6-mercaptopurine, 5-fluorouracil, cytarabine and 6-thioguanine SE: renal toxicity (methotrexate)

E. Natural products – cell-cycle specific (M phase) Ex. plant alkaloids (vinblastine, vincristine) and taxanes (paclitaxel, docetaxel) SE: cause peripheral neuropathy

F. Topoisomerase I inhibitors – cell-cycle specific (G1 phase) Ex. irinotecan, topotecan

G. Topoisomerase II inhibitors – cell-cycle specific (S phase) Ex. etoposide, amsacrine

H. Hormones – cell-cycle specific (M phase) Ex. tamoxifen, androgens, flutamide, aminogluthetimide, corticosteroids SE: hypercalcemia (tamoxifen), masculinization (androgens); gynecomastia (flutamide); sodium and water

retention and cushing’s disease (corticosteroids)

Immunotherapy – use of biologic response modifiers destroy or interfere with tumor activities; to help modify the host’s biologic response to tumor cells

A. Types: Interferons Lymphokines & cytokines (interleukin-2) Monoclonal antibodies (traztuzumab) Colony stimulating factors

B. Side effects Influenza-like symptoms, fatigue, N&V, neutropenia (INF), cardiotoxicity (traztuzumab),

Radiation Therapy – use of ionizing radiation to cause damage and destruction to cancerous growths

A. Effect: Radiation ® damage at the cellular level Indirectly: water molecules w/in the cell are ionized Directly: causes strand breakage in the double helix of DNA Not every cell is damaged beyond repair

B. Use to cure, for palliation, combined w/ surgery PreOP: to reduce size of tumor PostOP: to retard or control metastasis

C. Administration External – involves electromagnetic rays

1. Orthovoltage machines – superficial lesions2. Megavoltage (Cobalt-60) – deeper structures3. Linear accelerators – deep lesions; less harmful

Internal (Brachytherapy) – injection/implantation of radioisotopes proximal to cancer site for a specific period of time1. Sealed implants – radioisotope with a container and doesn’t contaminate body fluid2. Unsealed (radioactive iodine) – radioisotope without a container and contaminates body fluid

Principles of Radiation Protection (DTS) A. Distance. Maintain a distance of at least 3 ft. when not performing nursing procedures.B. Time. Limit contact for 5 min each time, a total of 30min/shift.C. Shielding. Use lead shield during contact with client.

Nursing Interventions for Radiotherapy Side-EffectsA. Skin reactions (erythema, desquamation, atrophy, necrotic/ulcerative lesions, depigmentation)

Keep area dry Wash area w/ water, no soap, pat dry, do not rub Do not apply ointments, powders or lotion, heat Use soft cotton fabrics for clothing Force fluid – 2000-3000 ml/day Apply cornstarch or olive oil

B. Bone marrow suppression Monitor blood counts weekly Good personal hygiene, nutrition, adequate rest Teach signs of infection to report to physician Reverse isolation

C. Hemorrhage (platelets are vulnerable to radiation)

Monitor platelet count Avoid physical trauma or use of aspirin Teach signs of hemorrhage Monitor for signs of bleeding Use direct pressure over injection sites until bleeding stops

D. Fatigue (results from high metabolic demands for tissue repair & toxic waste removal) Plenty of rest and good nutrition

E. Stomatitis Administer analgesics before meals Bland diet, no smoking/alcohol Good oral hygiene/ saline rinse q 2 hrs Sugarless lemon drops or mint to salivation

F. Nausea & vomitingG. Weight loss (anorexia, pain & effect of Ca)H. DiarrheaI. HeadacheJ. Hair loss/ alopeciaK. CystitisL. Social isolation

Bone Marrow Transplantation A. Used to treat

Acute lympphoblastic leukemia Acute myelogenous leukemia Aplastic anemia Chronic myelogenous leukemia

B. Types: Allogeneic BMT: bone marrow comes from a healthy donor (usually immediate family member) Autologous BMT: client is given own bone marrow

Diagnostic Tests

A. Blood Tests Blood chemistries, complete blood count and other specialized assay can provide important information about

the extent of malignancy and the effectiveness of therapy. Tumor markers – substances that are specific to a particular tumor and can be used to screen, diagnose, assess

prognosis, evaluate response to treatment and check for tumor recurrence can be used to measure hormones, oncofetal proteins secreted by malignant tumors:1. Carcinoembryonic antigen (CEA) – bowel cancers; occasional lung and breast cancers2. Carbohydrate antigen 19-9 (CA19-9) – colon and pancreatic cancer3. Carbohydrate 125 (CA125) – ovarian cancer4. Prostate specific antigen (PSA) – prostate cancer5. Beta Human Chorionic Gonadotropin (β-hCG) – hydatidiform mole, choriocarcinoma, testicular cancer6. Alpha-fetoprotein (AFP) – germ cell tumors, hepatocellular carcinoma, and metastatic cancer in the liver7. AFP-L3 (lectin-reactive AFP) – hepatocellular carcinoma8. Thyroglobulin – thyroid cancer9. Cancer antigen 15-3 (CA15-3) – breast cancer10. Mucin 1 (MUC1) – breast cancer11. Epithelial Tumor Antigen (ETA) – breast cancer12. Tyrosinase – malignant melanoma13. Melanoma-associated antigen (MAGE) – malignant melanoma14. LDH – testicular cancer

B. Cytologic tests These tests help detect suspected primary or metastatic disease and monitor therapy They cannot determine the location and size of a malignancy ASPIRATION TESTS – fine needle aspiration of body fluids permits evaluation of a palpable mass, a lymph node

or a lesion that has been localized x-rays. BONE MARROW ANALYSIS allows examination of bone marrow aspirate to identify leukemic cells; most

common collection site is the iliac crest; other sites: sternum (adult) and tibia (infants) PAPANICOLAOU TESTS – is widely used to detect cervical cancer, endometrial and extrauterine malignancy in

an asymptomatic patient. C. Endoscopy

These can be performed on the entire GIT, respiratory tract, urinary tract and peritoneal cavity.

D. Histologic tests Biopsy is a common procedure that provides a detailed description that helps classify malignancy

E. Nuclear imaging and Scanning Include CT, MRI and Radionuclide imaging

F. Radiographic test Are used to visualize internal body structures to detect, identify, and localize malignancy and guide biopsy. These include CXR, mammography

G. Ultrasonography This non-invasive procedure is used to evaluate organs and localize masses except the lungs and bones.

H. Stool occult examination Permits early detection of colorectal cancer, providing positive results in 80% of patients with this disorder

Nursing Interventions for CancerA. Relieve anxiety and ineffective coping

Encourage to express feelings Ineffective coping. Teaching, encouraging self-care within limitations, emphasizing abilities, encouraging the use

of coping strategies that have been successful in the past Support groups. ACS has local community information. Reach for recovery, groups that help patients cope with

ostomies resulting from cancer of the colon, bladder, LarynxB. Management to promote nutrition

Serve food in ways to make it appealing Consider patient’s preferences Provide small frequent meals Avoids giving fluids while eating Oral hygiene PRIOR to mealtime Vitamin supplements

C. Management to relieve pain Mild pain – NSAIDS

Moderate pain – Weak opiods (meperidine) Severe pain – Morphine Administer analgesics round the clock with additional dose for breakthrough pain

D. Management to improve body image Therapeutic communication is essential Encourage independence in self-care and decision making Offer cosmetic material like make-up and wigs

E. Management to assist in the grieving process Some cancers are curable Grieving can be due to loss of health, income, sexuality, and body image Answer and clarify information about cancer and treatment options Identify resource people Refer to support groups

F. Manage side effects of chemotherapy and radiotherapy

Nursing Care of Terminally Ill Patient – directed towards making the patient physically & psychologically as comfortable as possible

A. Nutrition High calorie & protein diet Small frequent feedings fluids intake, 1000-1500ml above the N

B. ActivityC. Prevent tissue breakdown & vascular complications

Frequent turning, skin massage, air mattresses Active and passive ROM

D. Observe for toxic reactions to tx (diarrhea)E. Supportive measures & drugs for pain reliefF. Maintain open communication with patient & familyG. Control of odor

Infectious organisms cause formation of offensive odors Frequent change of dressings

Oncologic emergencies – due to the disease or the treatmentA. Hypercalcemia

Most common life-threatening disorder associated with cancer

Lung cancer, breast cancer and multiple myeloma are the most prevalent malignancies associated with hypercalcemia

The cause of hypercalcemia is when cancer spreads to or invades the bones and when malignant cells release certain factors that cause calcium to be released from the bone

B. Syndrome of inappropriate antidiuretic hormone Found in small cell carcinoma of the lung and brain tumors (but also found in pneumonia, head trauma, strokes,

meningitis and encephalitis) Characterized by excessive release of antidiuretic hormone (ADH or vasopressin) from the posterior pituitary

gland or another source The result is hyponatremia, and sometimes fluid overload

C. Disseminated intravascular coagulation – a pathological activation of coagulation (blood clotting) mechanisms that leads to the formation of small blood clots inside the blood vessels throughout the body

D. Superior vena cava syndrome Result of the direct obstruction of the superior vena cava by malignancies such as compression of the vessel wall

by right upper lobe tumors or thymoma and/or mediastinal lymphadenopathy The most common malignancies that cause SVCS is bronchogenic carcinoma Leads to shortness of breath is the most common symptom, followed by trunk or extremity swelling

E. Spinal cord compression Develops when the spinal cord is compressed by bone fragments from a vertebral fracture The most common causes of cord compression are tumors, but abscesses and granulomas (e.g. in tuberculosis)

are equally capable of producing the syndrome Back pain, a dermatome of increased sensation, paralysis of limbs below the level of compression, decreased

sensation below the level of compression, urinary and fecal incontinence and/or urinary retention

General Promotive and Preventive Nursing ManagementA. Lifestyle ModificationB. Nutritional managementC. ScreeningD. Early detection

Types of Cancer

Prevention Detection

Lung Do not smoke NoneUterine Cervix Having one sexual partner lower risk; clean safe sex Regular pap smear every 1-3 yearsLiver Vaccination vs. Hepatitis B virus; Minimal alcohol

intake; avoid moldy foodsNone

Colon and rectum

Prudent diet of a variety of foods also with high fiber and low fat intake.

Regular medical check-ups after 40 years of age, yearly occult blood test in stools; digital rectal exam; sigmoidoscopy

Mouth Avoid smoking tobacco, betel quid chewing. Modify consumption of alcohol; cavity and dental hygiene.

Through dental check-ups each year

Breast No conclusive evidence Monthly self-exam and annual doctor exam; mammography for high risk groups of for >=50 yrs. Old; Female

Skin Avoid excessive sun exposure Skin self examProstate No conclusive evidence Digital trans-rectal exam (early diagnosis)