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Nursing Care of the Patient with
Cancer
Ju-An Broyles, RN, MSN, FNP
N200
Resources
CancerSourceRN.com http://www.cancer.org (American
Cancer Society)
http://www.nci.nih.gov/
Cancer Pathophysiology
Abnormal cells DNA Oncogenes Abnormal growth Cells become invasive Metastasis
Breast Cancer Cell
Cancer is classified by tissues or blood cells in which it
originates:
Glandular tissues (adenocarcinoma) Connective, muscle, bone tissue (sarcoma) Tissue of the brain and spinal cord (gliomas)
Pigment cell (Melanoma) Plasma cell (myeloma) Lymphatic tissue (lymphomas) Leukocytes (leukemia)
Cancer Risk Factors
Environmental Genetic susceptibility Host susceptibility Lifestyle
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Environmental
Viruses Chemicals Sunlight Radiation Tobacco use
Environmental
Lung cancer Aspirin and other NSAIDs Tamoxifen SERMs Finasteride
Genetic Susceptibility
About 5-10% of cancers have familialtendency
Examples of cancers that show familialinheritance are: retinoblastomas, breast,
ovarian, endometrial, colorectal, stomach,
prostate, and lung cancer
BRCA-1 (and 2) gene
Dietary Factors (Lifestyle)
Dietary factors related to 35% of allenvironmental cancers
Diet-
Host Susceptibility
Immune system Carcinogens
Host Susceptibility
New, additional cause of cancer is priortreatment with chemo or radiation therapy
for a prior malignancy
Can cause leukemias (latency period 2-5yrs) or solid tumors (10-20 years)
Prognosis for these are usually poor
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Seven Warning Signs and
Health Seeking Behaviors Nurses Role Primary prevention Secondary prevention
(early detection)
Seven Signs of Cancer
Change in bowel or bladder habits could be a sign of colorectalcancer.
A sore that does not heal on the skin or in the mouth could be amalignancy and should be c hecked by a doctor.
Unusual bleeding or discharge from the rectum, bladder or vaginacould mean colorectal, prostate, bladder or cervical cancer.
Thickening of breast tissue or a new lump in the breast is awarning sign of breast cancer. A lump in the testes could mean
testicular cancer.
Indigestion or trouble swallowing could be cancer of the mouth,throat, esophagus or stomach.
Obvious changes to moles or warts could mean skin cancer. Nagging cough or hoarseness that persists for four to six weeks
could be a sign of lung or throat cancer.
Benign vs Malignant Tumors
Benign Tumors
Malignant Tumors
Staging Cancer
TNMT: extent primary tumorN: Lymph node involvementM: Metastasis
Breast Cancer 70% occur in women over age of 70 BRCA1 & 2 gene Other risks
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Breast Cancer Locations
Breast assessmentSymptoms that may indicate breast cancer
Breast lump
* Breast pain
* Change in the size or shape of the breast* Swelling of the arm (lymphoedema)
* Dimpling of the breast skin* Involution or inversion of the nipple
* Axillary lymphadenopathy* Nipple discharge or bleeding
* Ulceration of the breast skin
* Bone or abdominal pain / jaundiceSymptoms requiring specialist referral
Lumps
* All new discrete breast lumps
* A new lump in pre-existing nodularityAsymmetrical nodularity persisting after menstruation
* Breast abscess
* Persistently refilling or recurrent cysts* Axillary lymphadenopathy
* Breast pain
* Pain associated with a lump* Persistent unilateral pain in a postmenopausal woman
Nipple discharge
* All women aged over 50 years
* Women aged below 50 years with:
* Bilateral discharge sufficient to stain clothes
* Blood-stained nipple discharge* Persistent discharge from a single duct
Family history
Breast Cancer 1:7 women will develop in lifetime in OC If already had breast cancer, 3-4x more
likely to develop it again
DetectionMammogram (5-17% missed cancers)Digital mammogramMRI (finds 2x cancers vs mammo+ US)Positron Emission Tomography scan-
radioactive sugar injected.
Self Breast Exam (SBE)
Breast Cancer-New treatments
Monoclonal Antibody therapy- Herceptin- Antiangiogenesis - Avastin
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Breast Cancer-New treatments
Chemotherapy-new version of Taxol,Abraxane, better tolerated tumors shrunk
better.
Aromatase Inhibitors-drugs preventestrogen from forming, used after 2 years of
tamoxifen in clinical trials
Breast Cancer
Breast cancer in men-approximately 1690new cases will be diagnosed in men this
year.
100x more common in women than men
Malignant Melanoma
*
Melanoma is a malignancy of pigment-producingcells (melanocytes)
Melanoma accounts for only 4% of all skin cancers
70% arise from pre-existing mole
Risks: excessive sunlight exposure, increased nevi
(moles), tendency to freckle from the sun, familyhistory, red hair, fair skin, blue eyes, susceptibility
to sunburn, celtic or scandinavian ancestry
(Melanoma rare in african-americans)
Malignant Melanoma Malignant Melanoma
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Colon Cancer
Colonoscopy versus Virtual Colonoscopy 1:20 will have colon cancer in lifetime Approximately 150,000 new cases each yr in USA Early detection critical; 5 yr survival rate is 92%. Growth of polyp: takes approximately 5 yrs to grow 1/2 inch,
takes approximately 5-10 years for these to become malignant
Colon Cancer
Higher risk in smokers Diets high in vegetables & fruits lower risk Right-sided (ascending colon) tumors present with
anemia, fatigue. Lesions can grow large without
obstructive symptoms as stool liquid in ascending
colon
Left sided (descending colon) tumors present withobstructive symptoms
Aspirin and Calcium (1500 mg) may lower risk
Tests to Diagnose Colorectal
Cancer
Digital rectal exam (detects 15%) Fecal occult bloood Sigmoidoscopy (2/3 of cancers detected) Colonoscopy-visualize, photograph, &
biopsy up to the ileocecal valve
Barium enema (detects lesions not visible orpalpable)
CT scan-detects cancer spread
Lab Tests Used in Cancer
Detection
Tumor Markers-
MRI-
Lab Tests Used in Cancer
Detection
Ultrasound: Mammogram: PET scans, CT scans
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Diagnosis
Self exam Stool guaiac Rectal exam &
sigmoidoscopy
Blood studies Tissue Biopsy Pap smear Digital exam PSA
Nursing Diagnosis
Anxiety r/t lack of knowledge Dx & Tx Disturbed self concept r/t Ineffective individual coping Sexual dysfunction r/t Knowledge deficit Altered Nutrition r/t intake, N & V,
anorexia
Potential for injury r/t susceptibility At risk for infection
Nursing Diagnosis
Pain r/t dx and tx Impaired physical mobility r/tActivity intolerance r/t malnutrition & tx
Noncompliance Collaborative: hemorrhage, infection,
bladder neck obstruction, many of the above
Etc.. Etc. Etc.
Nursing Care of Patient with
Cancer
Assessment for infection Bleeding Skin Problems Hair loss, body imageNutrition Pain Fatigue
Therapies
Surgery & lymphnode staging
chemotherapy radiation hormonal palliative treatment
Nurses role with Surgery patient
monitor VS good assessment
I & O wound complications
teachingpre-oppost-op
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Management of Cancer-Surgery
Diagnostic-Biopsy Primary Treatment- Prophylactic surgery Pallative-
Nurses role with Radiation
Safety distance length of time shielding
Teaching Prevent complications Expected side effects
Radiation Therapy
Goal: palliative, cure, or control of cancer. Types: electromagnetic, particulate (alpha,
beta, electron neutrons)
External (beam) or internal delivery(implant)
Safety interventions: Time, Distance,Shielding
Radiation Therapy
Cells that undergo frequent cell division aremost effected by radiation
Slower growing tissues are nearly resistant
Types of Radiation
External-amount of energy determine howdeep radiation can treat externally
Internal-high dose to a localized area;Implant (needles, seeds, beads into vagina,
abdomen, pleura, breast)
Radiation Therapy Ionizing radiation used to interrupt cell growth. High-energy particles Normal cells can tolerate a specified dose of radiation
before complications occur.
Cancers are most radiosensitive because they dividerapidly, are well-oxygenated, and poorly differentiated.
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Radiation Therapy
Ionizing radiation Pallative radiation can relieve symptoms
Radiation Safety-Implant
Teach patient:Stay 3 feet minimum away from others for 1-3
days after discharge
Minimize time with other individualsWash hands with plenty of soap and water after
void. Rinse bathroom sink and tub thoroughly
after each use
Radiation Safety-Implant Absorbent pads cover floor around toilet. Cover telephone,
overbed table with plastic, hampers marked radioactive
No pregnant staff member may care for patient Film badges worn by all staff entering room (at chest level) Verbal contact every 2 hours via telephone or call system
(or per hospital policy)
Double glove for handling urinals, bedpans, emesis basinsor any contact body fluids.
Instruct flush toilet 3 times with each use. Disposable food trays. Lead shield to be used if implants
Nursing Care of Patient with
Radiation Therapy
Protect skin and oral mucosa- assessmentfrequently, avoid ointments, lotions, or
powders to treated area. Teach weakness,
fatigue, etc is from therapy, not worsening
of cancer. Use lukewarm water, avoid
rubbing/scratching area, avoid sun, report
blistering. Apply vitamin A&D ointment to
irritated areas, avoid tight clothes
Radiation Therapy
If implant, protect caregivers Encourage rest periods throughout day Encourage adequate protein and calorie
intake
Chemotherapy
Destroys tumor cells by interrupting cellularfunctions and reproduction.
Each time tumor exposed to chemo,percentage of tumor cells (20-90%) are
destroyed.
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Chemotherapy
Chemo attacks rapidly dividing cells, cancercells are rapidly dividing cells
Other cells that divide rapidly Chemotherapy drugs remain in urine, stool,
saliva, blood, emesis up to 48 hours after
administration completed
Nursing Care for Patient
Receiving Chemo
Monitor for extravasation Nausea and vomiting Oral care Teach to flush toilet 2 x after each use Double latex gloves for 2 days after chemo for any
body secretions
Nursing Care for Patients
Receiving Chemo
Patients on bleeding precautions Incontinent patients Chemo spill kit Pathogen-free diet: no raw fruits, vegetables, tea,
pepper, avoid most spices except salt and sugar
Nurses role with Hormonal therapy
Teaching side effects Tamoxifen, Lupron,
Zoladex, etc
Therapeuticcommunication
sexuality impotence
Nursing Care of Cancer Patient
Problem: FatigueMost common and most distressing symptom,
No single cause
Ways to Manage Fatigue
Encourage exercise. Encourage rest periods throughout day,
space activities
Identify anxiety/depression, refer or treat Avoid patient chilling
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Mucositis/Stomatitis
cancersourceRN.com the chemotherapy made my mouth and throat so raw
I could not talk or swallow my own saliva. The
constant pain in my throat was like being stuck with a
fiery hot poker. Thank goodness for Morphine-a
cancer patient suffering from stomatitis
Mucositis/Stomatitis
Signs & symptoms include taste changes,oral pain, ulceration, edema, bleeding, drymouth, infection,altered nutritional status
40% of people with cancer will develop oralcomplications
Can occur 2-14 days from the time ofchemo administration, varies with type of
chemo
Nursing Care-Mucositis
Nursing care includes: assessment-normalmucosa is pink, moist, clean, intact
(Use flashlight if needed), assess forerythema, edema, signs of candidiasis
(white patches), ulcers, exudate, discolored
lesions, pallor. Check for altered texture
and shininess, amount of saliva, coating,
bad odors, cracks, fissures, blisters
Nursing Care-Mucositis Teach to avoid spicy food, alcohol based
OTC mouthwashes, good oral hygiene
including flossing, brushing, rinsing,
moisturizing.Toothpastes with sodium
bicarb aid in dissolving mucus, reduce
acidity of inflammation. Rinse agents:
water, saline, salt&soda, 1/2 strength
H2O2 orPeridex mouthwash. At risk for
dental caries as can have 95% decline in
salivation
Nursing Care of Mucositis
Topical anesthetics (20% Benzocaine,viscous lidocaine, Orabase)
oral capsaicin in form of candy is beingstudied
Gels that congeal to form an occlusivecovering: Zilactin, Oratect, Gelclair
Mycelex troches, Mycostatin, Bacitracin
Nurses role with Palliative Care
We cant save everyone We can care for all. DNR does not = no care Although you cant save their
life, be their lifesaver.
Improve pain control & qualityof life
Reduce side effects
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