Nursing Care of the Client with Cancer Cancer Background A.Definition 1.Family of complex diseases...

Nursing Care of the Client with Cancer

Cancer BackgroundA.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 Prevalence1. Cancer accounts for about 25% of

death on yearly basis2. 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

Nursing Care of the Client with Cancer 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 general5 Diet: certain preservatives in pickled, salted foods; fried foods; high-fat, low fiber foods; charred foods, high fat foods, diet high in red meat

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 screenings2. 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. Cell cycle is under control of cyclins, and suppresor gene products which control process by working with enzymes;

cyclins promote cell division suppresor gene products limit cell

division 3. Forms the basis of how some

chemotherapeutic agents work against cancers


Theories of Carcinogenesis (what causes cancer to occur)

1. Cellular Mutation a. Cells begin to mutate (change the DNA to unnatural

cell reproduction) 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 but are damaged3. Exposure to Known Carcinogens a. Act by directly altering the cellular DNA (genotoxic) b. Act by affecting the immune system (promotional)


4. Viruses viruses break the DNA chain and mutates

the normal cells DNAEpstein-Barr virusHuman papilloma virusHepatitis virus

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. Can initiate and promote cancer b. Examples: hydrocarbons in soot ; arsenic in

pesticides; chemicals in tobacco7. Physical Agents a. Exposure to radiation

Ionizing radiation found in x-rays, radium, uranium UV radiation

Sun, tanning beds

8. Immune function1. Protects the body from cancerous cells2. Increased rate of cancer in immunocompromised pts


Neoplasms: also called tumors (mass of new tissue that grows independently of surrounding organs

1. Types of neoplasmsa. 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 metastasizea. 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


C. Malignant neoplasms can recur after surgical removal of primary and secondary tumors and other treatments

D.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

E. Malignant cells progress in deviation with each generation and do no stop growing and die, as do normal cells

F. Malignant cells are irreversible, i.e. do not revert to normal

G.Malignant cells promote their own survival by hormone production, cause vascular permeability; angiogenesis; divert nutrition from host cells

The steps of metastasis


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 G. Motor and sensory deficits

Cancer invades bone, brain or compresses nervesh. Respiratory difficulties

a. Airway obstructionb. Decreased lung capacity


2. Hematologic Alterations: Impaired function of blood cells1. Secondary to any cancer that invades the bone marrow (leukemia)2. May also be caused by the treatment

a. Abnormal wbc’s: impaired immunity b. Diminished rbc’s and platelets: anemia and clotting

disorders3. Infections: fistula development and tumors may become

necrotic; erode skin surface4. Hemorrhage: tumor erosion, bleeding, severe anemia5. 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 a. Types of cancer pain 1. Acute: symptom that led to diagnosis 2. Chronic: may be related to treatment or to progression

of diseaseb. 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 imbalances9. Psychological Stress a. Cancer equals death sentence b. Guilt from poor health habits c. Fear of pain, suffering, death d. Stigmatized


Collaborative CareA. Diagnostic Tests: used to diagnose cancer1. Determine location of cancer a. Xrays b. Computed tomography c. Ultrasounds d. Magnetic resonance imaging e. Nuclear imaging f. Angiography2. 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 metastasis4 Direct Visualization a. Sigmoidoscopy b. Cystoscopy c. Endoscopy d. Bronchoscopy e. Exploratory surgery; lymph node biopsies to

determine metastases


Other non-specific testsa. CBC, Differentialb. Electrolytesc. Blood Chemistries: (liver enzymes:

alanine aminotransferase (ALT); aspartate aminotransferase (AST) lactic dehydrogenase (LDH)


Treatment Goals: depending on type and stage of cancerA.Cure 1. Recover from specific cancer with treatment 2. Alert for reoccurrence 3. May involve rehabilitation with physical and

occupational therapyB.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. Effects are systemic and kills the

metastatic cells 2. Often combinations of drugs in specific

protocols over varying time periods Much more effective then a single agent

Consider the timing of the nadir of each drug• The time when the bone marrow activity and WBC counts

are at their lowest levels after chemo• Different times for different drugs

3. 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


B. Classes of Chemotherapy Drugs1. Alkylating agents 1. Action: create defects in tumor DNA 2. Examples: Nitrogen Mustard, Cisplatin2. Antimetabolites 1. Action: similar to metabolites needed for vital cell

processes Counterfeit metabolites interfere with cell division

2. Examples: Methotrexate; 5 fluorouracil 3. Toxic Effects: nausea, vomiting, stomatitis, diarrhea,

alopecia, leukopenia3. Antitumor Antibiotics 1. Action: interfere with DNA 2. Examples: Actinomycin D, Bleomycin 3. Toxic Effect: damage to cardiac muscle


4.Antimiotic agents 1. Action: Prevent cell division 2. Examples: Vincristine, Vinblastine 3. Toxic Effects: affects neurotransmission,

alopecia, bone marrow depression

5.Hormone agonist 1. Action: large amounts of hormones upset the

balance and alter the uptake of other hormones necessary for cell division

2. Example: estrogen, progestin, androgen

6.Hormone Antagonist 1. Action: block hormones on hormone-

binding tumors (breast, prostate, endometrium; cause tumor regression Decreasing the amount of hormones can decrease

the cancer growth rate Does not cure, but increases survival rates

2. Examples: Tamoxifen (breast); Flutamide (prostate)

3. Toxic Effects: altered secondary sex characteristics

7. Hormone inhibitors Aromatase inhibitors (Arimidex, Aromasin)

Prevents production of aromatase which is needed for estrogen production

Used in post menopausal women Side effects

• Masculinizing effects in women• Fluid retention


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).

Administration of chemotherapeutic agentsa. Trained and certified personnel, according to established

guidelinesb. Preparation 1. Protect personnel from toxic effects

Drugs absorbed through skin and mucous membranes Protective clothing and extreme care

2. Extreme care for correct dosage; double check with physician orders, pharmacist’s preparation

c. Proper management clients’ excrement


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

a. If the drug is a vessicant it may result in pain, infection and tissue loss

e.Types of vascular access devices1. PICC lines (peripherally inserted

central catheters)2. Tunnelled catheters (Hickman,

Groshong)3. Surgically implanted ports

(accessed with 90o angle needle

Hickman Catheter

Portacath

PICC Line


Managing side effects of chemotherapyA. Nausea and vomiting

80% of patients will develop it Antiemetics such as Zofran, Tigan,

Compazine as well as Ativan to control the symptoms

Monitor for dehydration and need for IV fluids

B. Bone marrow suppression Decreased number of RBC

Leads to hypoxia, fatigue Hgb 9.5-10 gm/dl require oral iron supplements Hgb below 8 gm/dl require transfusion May use Epogen to stimulate RBC production

Decrease number of WBC (normal 4,500-11,000 mm3) especially neutrophils (normal 3,000-7,000 cells/cc) Neutropenia-count below 2000 Pt at extreme risk for infection May order granulocyte colony stimulating factor (leukine) to

stimulate bone marrow to increase WBC count

Neutropenic precautions Private room Good handwashing Monitor temp q 4 hours, monitor for chills, UTI, pneumonia Limit visitors to healthy adults No flowers or plants Monitor neutrophil count

Thrombocytopenia Drop in platlet count (normal 150,000-400,000/mm3)

below 100,000 Test pt for bleeding in stool and urine Avoid punctures for IV or IM Handle pt gently Use electric razor Avoid placing foley or rectal thermometers Avoid oral trauma with soft bristle brushes, avoid

flossing, avoid hard candy Watch for ALOC, pupil changes that might indicate

intracranial bleeds Stool softeners to avoid straining

C. Mucocitis Inflammation and ulceration of mucous

membranes and entire GI tract Rinse mouth with ½ normal saline and ½

peroxide every 12 hours Topical analgesic medication Avoid mouthwashes with alcohol Avoid spicy or hard food Watch nutritional status

D. Alopecia Hair loss 2-3 weeks after treatment is started Affects all the hair, including eyebrows,

eyelashes Within 4-8 weeks after treatment hair begins

to grow back Before hair loss, have the pt pick out a wig

that is similar to hair color

E. Peripheral neuropathy Numbness and tingling to fingers and toes

in a glove and sock pattern May cause gait and possible fall problems

F. Provide emotional and spiritual support to patient and families


Surgery 1. Diagnosis, staging, and sometimes treatment of cancer 2. May be prophylaxis or removal of at risk tissue or organ

prior to development of cancer (breast cancer) 3. Involves removal of body part, organ, sometimes with

altered functioning (e.g. colostomy) 4. Debulking (decrease size of) tumors in advanced cases 5. Reconstruction and rehabilitation (e.g. breast implant

post mastectomy) 6. Palliative surgery to improve the quality of life

Removal of tumor tissue that is causing pain or obstruction 5. Psychological support to deal with surgery as well as

cancer diagnosis


Radiation Therapy1. Treatment of choice for some tumors to kill or reduce tumor, relieve pain or obstruction

Destroy cancer cells with minimal exposure to normal cells Cells die or are unable to divide

2. Delivery a. Teletherapy (external): radiation delivered in

uniform dose to tumor Beam radiation

b. Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it in the form of seeds

Radiation source within the patient so pt emits radiation for a period of time and is a hazard to others

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 Private room Caution sign on the door for radioactive material Dosimeter film badge by staff No pregnant staff Limit visitors to ½ hour per day and keep them at

least 6 ft from the source


4. Treatment Schedules a. Planned according to radiosensitivity of

tumor, tolerance of client b. Monitor blood cell counts5. Side Effects a. Skin (external radiation): blanching, erythema,

sloughing, breakdown Use mild soak Dry skin with a patting motion, not rubbing Don’t use powders or lotions unless prescribed by

radiologist Wear soft clothing over the site Avoid the sun and heat

b. Ulcerated mucous membranes: pain, lack of saliva (xerostoma)

c. Gastrointestinal: nausea and vomiting, diarrhea, bleeding, sometimes fistula formation

d. Radiation pneumonitis 1-3 months after treatment Cough, SOB, fever Treated with steroids to decrease inflammation


Monoclonal antibodies (inoculate animal with tumor antigen and retrieve antibodies against tumor for human) Antibodies target specific substances

needed by the cancer cell for growth (Herceptin for breast cancer)

Gene therapyexperimentalMay insert gene into the tumor cells to

make them more susceptible to being killed by antiviral agents

May insert genes for cytokines that increase their effectiveness in killing cancer cells

Angiogenesis inhibitor drugs prevent new blood vessels from

forming and delivering blood to the tissue


F. Bone Marrow Transplantation and Peripheral Blood Stem Cell Transplantation

1. Stimulation of nonfunctioning marrow or replace bone marrow 2. Common treatment for leukemiasG. 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 Care of the Client with Cancer Nursing Diagnoses for Clients with CancerA. 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, stigmaC. 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 InfectionE. Risk for Injury 1. Organ obstruction 2. Pathological fracturesF. 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 nutritionG. 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. obstruction of venous system with

increased venous pressure and stasis; facial and neck edema with slow progression to respiration distress Late signs are cyanosis, decreased cardiac output

and hypotension

2. Treatment: respiratory support; decrease tumor size with radiation or chemotherapy

Compression of the superior vena cava in SVC syndrome

C. Sepsis and Septic Shock 1. Early recognition of infection

Patients at risk secondary to low WBC and impaired immune system

2. Treatment: prompt intervention with antibiotics and vasopressors

D. DIC disseminated intravascular coagulation Triggered by severe illness, usually sepsis

in cancer patients Abnormal clotting uses up existing clotting

factors and platelets quickly then the pt hemorrhages

Mortality rate is 70% Prevention of sepsis is key


E. Spinal Cord Compression 1. Pressure from expanding tumor or

vertebral collapse can cause irreversible paraplegia

2. Back pain initial symptom with progressive paresthesia and paralysis Paralysis is usually permanent

3. Treatment: early detection High dose corticosteroid to decrease the swelling radiation or surgical decompression

F. Obstructive Uropathy1. Concern: blockage of urine flow;

undiagnosed can result in renal failure2. Treatment: restore urine flow

G. Hypercalcemia 1. High calcium (normal 9-10.5) usually from bone metastases 2. May also come from cancer of the lung, head, neck, kidney

and lymph nodes that secrete parathyroid hormone that causes the bone to release calcium

2. Symptoms include fatigue, muscle weakness, polyuria, constipation, progressing to coma, seizures

3. Treatment restore fluids with intravenous saline which also increases the

excretion of calcium loop diuretics increase calcium excretion Calcium chelators such as mithracin Inhibit calcium resorption from the bone with calcitonin,

diphosphonate

H. Tumor Lysis Syndrome 1. Occurs with rapid necrosis of tumor cells

with chemotherapy When tumor cells die they release potassium and

purines Potassium (norm 3.5-5.5) elevation causes cardiac

arrhthymias, muscle weakness, twitching, cramps Purines convert to uric acid which causes renal

failure, flank pain, gout when elevated above 10 mg/dl

Hyperphosphatemia with secondary to hypocalcemia causes heart block, HTN, renal failure

Treatment Hydration Instruct pt to increase fluid intake before

and after chemo May need IV hydration Diuretics to increase urine flow Allopurinol to increase uric acid excretion May need dialysis


I. SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion)

1. Ectopic ADH production from tumor leads to excessive hyponatremia

2. holds onto too much fluid which decreases sodium level (normal 135-145)

3. Symptoms Weakness, muscle cramps, fatigue, ALOC, headache, seizures

2. Treatment: restore sodium level Fluid restriction Increase sodium Antibiotic demeclocycline works in opposition to ADH

Limits ADH effect on distal renal tubules so they can excrete water

Nursing Care of the Client with Cancer Cancer Background A.Definition 1.Family of complex diseases...

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Transcript of Nursing Care of the Client with Cancer Cancer Background A.Definition 1.Family of complex diseases...