Presentation on theme: "Oncology Understanding Medical Surgical Nursing 4th ed., Ch 11"— Presentation transcript:
1Oncology Understanding Medical Surgical Nursing 4th ed., Ch 11 OBJECTIVES:1. Explain the differences between benign & malignant tumors.2. List risk factors for the development of cancer.3. State 7 warning signs of CA.4. Define terms used to name & classify CA.5. List the most common sites of CA in men & women.6. List nursing responsibilities in the care of patients having diagnostic tests to detect possible CA.7. Explain the nursing care of clients undergoing each type of CA therapy: surgery, radiation, chemotherapy, biologic response modifiers.
2Health StatisticsAmerican Cancer Society:Males: over ½ Prostate, lung, & colorectalWomen: ~½ breast, lung, & colorectalChildren (0-14yrs)Colorectal CA is the 3rd most common CA in both men & women.
3Health Statistics U.S. 2014 Deaths CA is the 2nd leading cause of death in the US, exceeded only by heart disease.Breast, Prostate, Lung, & Colorectal CA’s account for ½ of all deaths, men & women.
4Older Adult Considerations More cases of CACA î with agingS&S of CA may be misdiagnosed
5Cells that reproduce abnormally & in an uncontrolled manner. Cancer (CA)Large group of diseases characterized by uncontrolled growth & spread of abnormal cells. (American Cancer Society)Neoplasms or TumorsCells that reproduce abnormally & in an uncontrolled manner.
6Normal Cell GrowthUniform shapeCell cohesivenessControlled growthWell differentiatedProgrammed cell death (apoptosis)
7Cancer Pathophysiology CA cells divide & multiply, in an abnormal manner.Mutation of Cellular GenesAbnormal Cell GrowthNo Cell Division LimitLack of Contact Inhibition
8Cancer Cell GrowthAbnormal appearanceLack of cohesivenessRapid, disorderly divisionPoorly differentiatedNo apoptosis
9Benign TumorsSlow, steady growthRemains localizedUsually contained within a capsuleSmooth, well-defined; movable when palpatedResembles parent tissueCrowds normal tissueRarely recurs after removalRarely fatal
10Malignant Tumors Rate of growth varies – usually rapid Metastasizes Rate of growth varies – usually rapidMetastasizesRarely contained within a capsuleIrregular; more immobile when palpatedLittle resemblance to parent tissueMay recur after removalFatal without treatment
11MetastasisProcess by which tumor cells are spread to distant parts of body; used to describe movement of CA cells from primary to secondary site.Invade Blood or Lymph VesselsMove by Mechanical MeansLodge & Grow in New Location
12CarcinogenesisThe process by which normal cells are transformed into CA cells.Etiology:Carcinogen ExposureInitiationPromotion
13CarcinogenesisInitiationCarcinogens: CA causing agentsRepair itselfPermanently ∆’ed, don’t cause CATransformed & produce new line of CA cells
14PromotionProcess by which CA promoters aid in alternation or injury to DNA.
15ProgressionThe expression of malignant mutation acquiring more aggressive characteristics over time.
17Most Common CancersMenProstateLungColonWomenBreastLungColon
18Skin Cancer Malignant lesion of skin; may or may not metastasize Types: basal cell, squamous cell, malignant melanomaAssessment: change in color, size, shape of preexisting lesion; pruritus; local sorenessInterventionsInstruct in preventive measures (limiting exposure to sun, use of sunscreens)Instruct to monitor lesions for changes, nonhealing lesions; report to primary health care provider immediatelyAssist with surgical excision of lesion as prescribed
19LeukemiaMalignant exacerbation in number of leukocytes, usually at immature stage, in bone marrowData collectionNormal, elevated, or reduced white blood cell count; decreased H/H; thrombocytopenia; positive bone marrow biopsy; anorexia; fatigue; bleeding; fever; lymphadenopathy; splenomegaly; bone pain, swelling19
20Lymphoma: Hodgkin’s Disease Malignancy of lymph nodes; originates in single lymph node or single chain of nodesData collectionPresence of Reed-Sternberg cells in nodesFever; malaise; night sweats; anorexia; anemia & thrombocytopenia; enlarged lymph glands, including nodes, spleen, liver20
21Hodgin’s disease cont’d characterized by painless, progressive enlargement of lymphoid tissueInterventionsProvide care before & after external radiation as prescribedProvide care before & after chemotherapy as prescribedMonitor for signs of infection, bleedingFollow bleeding precautions
22Non-Hodgkin’s lymphoma (NHL) Any of a heterogeneous group of malignant tumors involving lymphoid tissue.
23Lung Cancer Malignant tumor of lung; may be primary or metastatic CausesCigarette smoking; exposure to environmental pollutants; exposure to occupational pollutantsData collectionCough; dyspnea; hoarseness; hemoptysis; chest pain; anorexia; wt loss; weaknessInterventionsPlace in Fowler’s positionAdminister oxygen as prescribed23
24Lung CASmall-cell lung CA: hormonal cellsNon-small lung CA:-squamous-cell: larger airways-adenocarcinomas: (large-cell carcinomas), in secretory portion-bronchoalveolar carcinomas: small air sacs, or alveoli
25Multiple MyelomaMalignant proliferation of plasma cells, tumors within boneData collectionBone, skeletal pain, especially in ribs, spine, pelvisOsteoporosisRecurrent infections; fatigue; anemia; thrombocytopenia; granulocytopenia; elevated uric acid & calcium serum levels
26Risk factors Smoking Exposure to radiation Exposure to environmental & chemical carcinogensSmokeless tobaccoFrequent heavy consumption of alcohol
27Risk factorsDietary habitsPickled, smoked, charbroiledHigh-fat, low-fiber dietsHigh-fat dietsDiet low in vitamins A, C, & E
29Genetic Susceptibility: Hereditary Cancers~ 90% of cancers are not inheritedGenetic Susceptibility:Postmenopausal breast CALung CA – SmokersLeukemia – identical twinNeuroblastoma – siblingsColon CA – breast CA
30American Cancer Society Cancer’s 7 Warning Signals: CAUTION Change in bowel or bladder habitsA sore that does not healUnusual bleeding or dischargeThickening lump in breast or elsewhereIndigestion or swallowing difficultiesObvious ∆ in warts or molesNagging cough or hoarseness
32Breast Self-Examination (BSE) Performing BSE7 to 10 days after mensesIf postmenopausal or posthysterectomy, select specific day of month, perform regularlyClient instructionsIn shower or bath, examine breastsUse pads of second, third, and fourth fingers to press firmly on every part of breasts, using right hand to examine left breast and vice versaUse small circular motions in a spiral or up and down motion so that entire breast is examined, checking for any lump, knot, thickening of tissue32
33Breast Self-Examination (BSE) (continued) Look at breasts in mirror, raising arms over head to determine any changes in size, dimpling of skin, changes in nipple, asymmetry; repeat with hands on hipsLying down, feel breasts as when in shower or bath; when examining right breast, place right hand behind your head and vice versa for left breastAny changes noted should be reported immediately to health care provider
34Testicular Self-Examination (TSE) Performing testicular self-examinationSelect day of month; perform on that day every monthClient instructionsIn shower, gently lift each testicle; each one should feel like an egg: firm but not hard, smooth with no lumpsUsing both hands, place middle fingers on underside of each testicle, thumbs on top; gently roll testicle between thumb and fingers to feel for swelling, lumps, or massAny changes noted should be reported immediately to health care provider
36Diagnosis of CABiopsy: sample of tissue for pathological examination.Incisional bx: removal of a portion of tissue for examination.Excisional bx: removal of complete lesion, with little or no margin of surrounding normal tissue removed.
37Diagnosis of CancerNeedle aspiration bx: aspiration of fluid or tissue by means of needle.Endoscopy: directly visualize an internal structure through a body cavity or through a small incision; can also obtain cells or tissue.
41Staging http://www.youtube.com/watch?v=X8MEoi4Tqho TumorNodesMetastasisIndicate tumor size, spread to lymph nodes, & extent of metastasis.Direct tx, predict prognosis, & contribute to CA research.
42T* SubclassesT×: tumor can’t be adequately assessedTo: no evidence of primary tumorTis: carcinoma in situT1, T2, T3, T4: progressive î in tumor size & involvement regional lymph
43Nt SubclassesN×: regional lymph nodes cannot be assessedNo: no regional lymph nodes cannot be assessedN1, N2, N3: î involvement regional lymph nodes
44M‡ SubclassesM×: not assessedMo: no (known) distant metastasisM1: distant metastasis present, specify site(s)
45GradingHistopathologyG1: well differentiatedG2: mod well-differentiatedG3: poorly differentiatedG4: undifferentiated
46Staging Classification for CA Stage 1: malignant cell confinedStage 2: limited spread, local area, nearby lymph nodes.Stage 3: larger or spread to nearby tissues or both; regional lymph node likely involved.Stage 4: metastasized to distant parts of body.
48Cancer TherapiesSurgery removal of all malignant cells; may include removal of tumor, surrounding tissue & regional lymph nodes.Preventive, Diagnostic, CurativePalliative: relieve or reduce intensity of uncomfortable symptoms. [not a cure]Reconstructive
49Laser SurgeryLaser beam vaporizes tissue with little bleeding & low risk of infection.ophthalmologygynecologyurologyneurosurgeryotolaryngology
50Nursing Interventions Monitor VSsMonitor labsMonitor client’s wt.Monitor I&OMonitor for bleeding, S&S of infectionPsychosocial issue
51Nursing Interventions When surgery may result in a Δ of body image, client may benefit from support groups:The American Cancer SocietyReach to RecoveryThe Lost Chord ClubI Can CopeLook Good, Feel GoodThe Ostomy Club
52Radiation TherapyCure or control CA that has spread to local lymph nodes or to tx tumors that can’t be removed.Preop to ↓ size of tumorPostop to destroy malignant cells not removed by surgery.
53External Radiationtx’s based on radiologist’s recommendations. ~ 5x/wk for 2 to 8 wks.Directed toward superficial lesions or targeted to deeper structures within body.Body marked, not washed off
54Nursing Interventions External RadiationNursing InterventionsMarking areas to be radiatedExplain procedure & instruct pt on how to protect markingsSkin care & protection from sunlightAvoid applications of heat or cold
55Nursing Interventions Cont’d External RadiationNursing Interventions Cont’dDiet- high protein & caloriesFluid intake: 2 or 3 quarts/dayAssess for lethargy & fatigueProvide frequent periods of rest
56Nursing Interventions Cont’d External RadiationNursing Interventions Cont’dMucositisFrequent oral careAdvise use of neutral mouthwash (diphenhydramine (Benadryl) & waterDiscourage use of alcohol & tobacco.Avoid very cold foods & drinks.
58Internal radiation safety measures (Sealed) Private roomSign on door – radiation areaTime - film badges. (30 mins./shift)4. The pt. Must be as self-sufficient as possible.5. The radioactive material may leave the pt. Accidentally; immediately notify physician & radiation safety personnel.
59Pts will receive the following instructions Restricted to your room.Use disposable eating utensils. These utensils should be placed in special waste container after use.Wear gloves when handling items that are not protected by coverings, such as personal items the pt. may wish to take home. Flush toilet 2 or 3 times after each use. This will insure that all radioactive urine is washed from toilet bowl.Avoid physical contact with visitors.
60Visitors have the following restrictions Visits should be limited to 30 hour/day. No pregnant women or persons under age 18 should visit the patient without special permission.Remain at least 6 ft. from the pt.Must be protected with gowns, shoe covers, & gloves. Should not handle any items in the room.Must not smoke, eat, or drink while in the client's room.
61Radioactive implant (brachytherapy) Usually combined with a course of external radiation therapy to ↑ dosage to a specific site.Visitors limited to 60 mins. Standing away from area.Liquid Radiation Tx (Zevalin therapy)Non-Hodgkins’s lymphoma
62Internal radiation safety measures UnsealedAdditional considerations:GlovesContaminated materials may require special care. (lead-lined container & long-handled forceps); Follow hospital policy for radioactive waste cleanup
69Chemotherapy Medications Different Antineoplastic Classes Are GivenDifferent classes affect different stages of the CA’s life cycleAllows lower dosages of each agentReducing toxicitySlowing development of resistance
70Alkylating AgentsMost widely used antineoplastic drugForm bonds or linkages with DNACalled alkylationChanges the shape of DNAPrevents normal DNA functionKill or slow down replication of tumor cellsAdverse effectBone marrow suppressionDamage epithelial cells lining GI tractCyclophosphamide (Cytoxan), nitrogen mustard
71AntimetabolitesChemically similar to essential building blocks of the cellResemble purines or pyrimidinesBuilding blocks of DNA & RNACA cells use this drug to construct proteins or DNABlock DNA synthesisKill CA cells or slow growthMethotrexate (Mexate)
72Antitumor Antibiotics Not widely prescribedInteract with DNA in a manner similar to alkylating agentsDoxorubicin (Adriamycin)
73Plant Alkaloids/Natural Products Structurally very differentCommon ability to arrest cell divisionSometimes called mitotic inhibitorsVincristine (Oncovin)
74Hormones & Hormone Blockers Used to slow growth of hormone-dependant tumorsCertain tumors stimulated by natural hormonesSpecific hormones or hormone blockers can block receptor sitesHormones used in CA chemotherapyUse of testosterone or antiestrogen to slow breast cancer (Tamoxifen)Estrogen to slow growth of prostate CAOther major class is corticosteroids
75Biologic Response Modifiers & Miscellaneous Antineoplastics Biologic response modifiers stimulate the body’s immune systemLimit the severe immunosuppressive effects of other anticancer drugsImmunotherapySome used to minimize the toxic effects of other antineoplastics
76Miscellaneous Anticancer Drugs Have Different Mechanisms of ActionsAsparaginase deprives CA cells of an essential amino acidMitotane (Lysodren) - similar to the insecticide DDTPoisons CA cells by forming links to proteins
77Miscellaneous Anticancer Drugs Others given to counteract the toxicity of antineoplasticsColony Stimulating Factors:G-CSF, GM-CSFOprelvekin (Neumega) - stimulates platelet productionEpoetin alfa; Erythropoientin EPO (Epogen) - stimulates RBC productionInterleukin-2 – stimulates T-cells
78Next Generation Drugstyrosin kinase inhibitors: a chemical that helps govern growth of CA cells. Targets a specific “receptor” site found on surface of CA cell.Iressa -bowel, breast, head, ovary, prostate, bladder & kidneyHerceptin (trastuzumab) –breast CAGleevec –chronic myelogenous leukemia
79Chemotherapy Side Effects Antineoplastic drugs:doxorubicin (Adriamycin): red urineBone marrow suppressionLeukopeniaThrombocytopeniaAnemiaN/V & diarrhea
80Chemotherapy Side Effects AlopeciaStomatitisReproductive AlterationsNeurotoxicity
83Biotherapy[immunotherapy] tx with agents derived from biological sources or affecting biological responses.Biological response modifiers (BRM)↑ & restores, or modifies host defenses against the tumors (CSFs, Neupogen, erythropoetin, GM-CSFs)
85Non-traditional approaches Alternative Therapies:BiofeedbackReflexologyHerbal supplementsEnzyme therapyReikiCultural factorsSpiritual factors
86Bone Marrow Transplantation (BMT) Tx leukemia -though high-dose chemotherapy, total body irradiationTypes of donor stem cellsAllogeneic, syngeneic, autologousProcedureHarvest: marrow harvested through multiple aspirations from iliac crest to retrieve sufficient bone marrow for transplantationConditioning: refers to immunosuppressive therapy regimen to eradicate all malignant cells
87Bone Marrow Transplantation Replacing diseased or damaged bone marrow with normally functioning bone marrow.Stem Cell TransplantsUsed in some solid tumor CA’s
89Bone Marrow Transplantation Nursing interventionsReinforce info., explained by physicians regarding expectations of specific tx’s.Allow pt express their feelings & enc. them to follow guidelines of conventional medical practice.
90Bone Marrow Suppression Nursing InterventionBone Marrow SuppressionMonitor CBC, & WBCAllow for periods of restPrevent overtiringProtect from infectionProtective isolation
91Hematopoietic SystemLeukopenia (low WBC’s d/t depression of bone marrow)Life-threatening infectionsNormal WBC: 4,500 – 11,000/mm³
92Neutropenia: a low absolute neutrophil count ANC measured is in the setting of chemotherapy for CA.A normal absolute neutrophil count (ANC) is above 1,500. An ANC less than 500 is defined as neutropenia & significantly ↑’s the risk of infection.
93Neutropenia↓ pneumonia, septicemia, infections.Tx: colony-stimulating factors (CSFs)Granulocyte colony-stimulating factors (G-CSF)Granulocyte CSF (filgrastim [Neupogen]), Granulocyte-macrohage CSF (GM-CSF) (sargramostim[leukine or Prokine]) SQ or IV.
94Nursing Interventions Neutropenic precautions:protective isolationMonitor VSReport î tempAssess for signs of infection
95Anemia: ↓ RBCs Fatigue Tx: recombinant human erythropoietin, or epoetin alfa (Epogen, Procrit) SQ or IV. (side effect: ↑ BP)TransfusionsNormal hemoglobin: g/dL female; g/dL maleNormal hematocrit: % female; 42-52% males
96Thrombocytopenia low platelets, d/t depression of bone marrow. Potential for bleeding 50,000 mm³Less than 20,000 mm³ spontaneous bleedingTx: TransfusionNormal Platelet Count: , ,000 mm³
97Nursing Interventions ThrombocytopeniaNursing InterventionsMonitor for bleedingVenous punctures or injections – apply pressure for 5 minsInstruct use of soft tooth brush, & electric razor.
98Integumentary SystemAlopecia loss of hair d/t destruction of hair follicles, never permanent.
99Stomatitis Tx: Viscous Xylocaine GI SystemStomatitis Tx: Viscous XylocaineCandida infection of mouth & esophagus Tx: nystatin p.o.Nausea, Vomiting & Diarrhea d/t breakdown of normal GI cells.Metoclopramide (Reglan)Check serum protein level for nutritional status
100Nursing Intervention - GI Antiemetics prochlorperazine (Compazine); promethazine (Phenergan)Serum albumin less than 3 g/dL indicates poor nutrition & possible need for supportDehydration, Anorexia, ConstipationCardiacPulm
101Physiological Symptoms or Psychological Responses GI SystemPhysiological Symptoms or Psychological ResponsesDepressionWithdrawal
102Pain ManagementPain - a late symptom of CATx: Opioids – MS, hydromorphone (Dilaudid), fentanyl, methadone. Sustained-release MS p.o. – MS Contin or Roxanol SR for terminally ill pts with painCocktails
103Pain ControlCauses of painBone destruction; obstruction of an organ; compression of peripheral nerves; infiltration or distention of tissue; inflammation or necrosis; psychological causes, such as fearInterventionsAssess pain as fifth VSCollaborate with pain management teamAdminister salicylates, acetaminophen (Tylenol), anti-inflammatories, opioid analgesics orally or parenterally as prescribedProvide nonpharmacological techniques of pain control
104Relationships of Food & CA Thought to be carcinogenic:Nitrates in cured & smoked foodsHigh-fat dietsExcessive caloric intakeAlcohol & cigarettes
105Relationships of Food & CA Certain diets seem to have health benefitsDiets high in fiberDiets rich in vitamin CDiets high in vitamin A
106Relationships of Food & CA Health benefitsPhytochemicals - anticarcinogenic.Legumes contain vitamins, minerals, protein, & fiberHigh intake of soy foods
107The Effects of CAMay cause unexplained wt. loss, weakness, early satiety, & anorexiaMay lead to loss of muscle tissue, hypoalbuminemia, & anemiaEffect of CA on the pt. depends on the location of the tumor
108Nutritional CareCalorie needs of the pt with CA are greater than before the illness.Pts who can eat normally tolerate the side effects of therapy better.Pts can form aversions to food, making anorexia worse.
109Nutritional CareSoft dietLow-residue dietHigh-protein, high-calorie diets and plenty of fluids for pts undergoing radiation or chemotherapy45 to 50 calories per kg of body weight per day
110Nutritional CareCarbohydrates & fat needed to provide energy & spare protein for tissue building & the immune system1.0 to 1.2 g of protein per kg of body wt. a dayMalnourished pts may need from 1.3 to 2.0 g of protein per kg of body wt. a day.Vitamins & minerals are essential.
111Nutritional CareEncourage foods that will ↑ appetiteSalad dressings, gravies, sauces, & syrupsSeveral small mealsDrugs to control nausea & pain.Nutritional supplements
112A pt. with CA may feel that comments to encourage eating are depressing reminders of the CA & the situation.How can the health care professional be helpful to the pt?
125Oncological Emergencies - Sepsis, disseminated intravascular coagulation (DIC)Maintain strict aseptic technique; administer antibiotics, anticoagulants, cryoprecipitated clotting factors as prescribedSyndrome of inappropriate antidiuretic hormone (SIADH)Tumors can produce, secrete, stimulate brain to synthesize ADHInitiate fluid restriction, increased sodium intake as prescribed; administer demeclocycline (Declomycin) as prescribedSpinal cord compressionOccurs when tumor directly enters spinal cordAssess for back pain, neurological deficits; prepare client for radiation, chemotherapy as prescribed125
126Oncological Emergencies (cont’d) . HypercalcemiaLate manifestation of extensive malignancy, often in clients with bone cancerMonitor serum calcium level; administer oral or parenteral fluids as prescribed; administer medications to lower calcium levels as prescribedSuperior vena cava syndromeOccurs when vein compressed, obstructed by tumor growthPrepare client for radiation therapy as prescribedTumor lysis syndromeOccurs when large numbers of tumor cells are destroyed rapidly, indicating CA tx is effectiveEncourage oral hydration; administer diuretics as prescribed